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Developing a framework for Resident Safety Risk Assessment

March 5, 2012
by Xiaobo Quan, PhD, EDAC; and Anjali Joseph, PhD, EDAC
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An evidence-based approach to long-term care design

Resident safety issues in LTC facilities—skilled nursing, assisted living and dementia/Alzheimer’s care facilities—have increasingly attracted attention from practitioners, researchers and decision makers in recent years. As one of the efforts to enhance resident safety, The Center for Health Design (CHD) worked with others to develop a Resident Safety Risk Assessment framework focusing on the design of the LTC physical environment. The Resident Safety Risk Assessment framework has been proposed for inclusion in the 2014 Facility Guidelines Institute, Proposed Volume 2: Guidelines for Design and Construction of Long Term Residential Health, Care, and Support, and Related Facilities.

The Resident Safety Risk Assessment is intended to serve as a broad evaluation framework for the key design areas that impact resident safety in various residential care settings (e.g., noise, light levels, design of outdoor spaces). To support its development, a literature review was conducted to identify research evidence that empirically supports the linkages between certain design elements and safety outcomes in LTC facilities and identifies areas where additional research is needed.


An extensive literature search was conducted through keyword searching in CHD’s database of evidence-based design literature, PubMed, EBSCOhost and other databases such as Google Scholar, as well as by examining several existing literature reviews on similar topics. The initial list of more than 100 publications was further narrowed down to 55 articles that empirically demonstrated the connection between the physical environment and resident safety outcomes in LTC and similar settings.

Based on the detailed analysis of the selected articles, a matrix was created to summarize the relationships between safety outcomes and environmental factors. The matrix includes the following information: research settings, key research findings, strength of evidence, literature reference information, the strength of evidence and design recommendations.


The resident safety outcomes were classified into six main categories: resident falls, resident elopement/unsafe exiting, sleep disorders, aggressions/disruptive behaviors, medical errors and healthcare-associated infections. The six safety outcomes were impacted by multiple environmental variables as shown in an abridged version of the matrix/framework (see table at end of article).

Research settings in the matrix only indicate where research has been conducted. Even though some research evidence was collected in only one or two types of LTC settings, the findings are likely applicable to other settings. The following is a brief summary of key findings.

Resident falls

Resident falls are one of the leading causes of resident injuries and liability claims in LTC. Research identified lighting, furniture, flooring, wander gardens and assistive or restrictive devices as the key environmental design elements impacting resident falls. The review found:

●  High lighting level and light glare reduction were associated with reduced fall risk.

●  Selecting low-height furniture, positioning furniture (e.g., beds) against walls and allowing more maneuvering space between furniture pieces were found to prevent residents from accidentally falling from beds or chairs and reduce fall-related injuries.

●  Flooring surface materials with small motifs and lowest contrast as well as soft sub-floor improved walking and reduced falls and fall-related injuries.

●  Residents with dementia who had access to wander gardens tended to experience fewer falls than those without access.

●  Appropriate configuration of grab bars in the bath and toilet areas may contribute to a reduction in resident falls in bathrooms.

●  Some restrictive devices, such as bedrails, were related to more severe injuries and should be avoided.

Resident elopement/unsafe exiting

Unsafe exiting may potentially cause great dangers or even deaths to residents with dementia. Environmental measures effective to reduce unsafe exiting behaviors among dementia residents included providing a soothing atmosphere, reducing visibility of exit doors and providing a safe outlet, such as a wander garden. Research found that:

●  A soothing and healing environment with appropriate nature scene artworks, plants, nature sounds, music and aroma could reduce anxiety and unsafe exiting behaviors.

●  Visual barriers (such as cloth panels covering door knobs and window blinds blocking outside views) helped hide exit doors and doorknobs, and reduced exit-seeking and unsafe exiting behaviors.

Sleep disorders

Sleep disorders may cause safety problems including falls, delirium, morbidity and mortality. Multiple environmental measures have been found to improve sleep quality by reducing nighttime awakenings and daytime sleep. These environmental measures included:

●  higher lighting level during daytime including exposure of bright light and sunlight

●  control of environmental disturbances (e.g. noise, light variation) during nighttime

●  single rooms preventing disturbances from roommates

●  outdoor spaces that provide exposure to nature and bright light for dementia residents

Aggressive/disruptive behaviors