Going Beyond ADA In Bathroom Design
When PAM opened its doors in December 2014, it included some unconventional features. For example, the toilets in its resident rooms were located 36 inches from the side wall, providing caregivers two sides—not just one—from which to assist residents. Additional bathroom improvements included roll-in trapezoidal showers with grab bars that allow for greater accessibility and maneuverability in assisted showering. These enhancements—and more—support PAM’s goal of providing person-centered care and safety to residents and staff in the 96-room skilled nursing facility that’s divided into six small houses supporting 16 residents each.
The process for building the case for these bathroom improvements started five years ago when the owner/operator analyzed minimum data set findings—the clinical indicators of long-term care residents' ability to care for their daily living activities such as walking, bathing, grooming, and toileting.
Statistical snapshots of Parker’s resident populations were also commissioned in preparation for the development of PAM, with data focused on the adequacy of existing ADA-compliant bathrooms in two of its recently renovated nursing homes.
The bathrooms in these homes offer a single, secure side wall-mounted handrail and back wall bar (above the toilet). The center line of the toilet room is 18 inches from the side wall, and the room features a 5-foot standard turning radius as prescribed by ADA guidelines.
The analysis yielded three primary findings:
· Bathroom assistance is prevalent. Approximately 85 percent of Parker’s skilled nursing residents receive bathroom assistance. Layout improvements, including open floor space and dual-side grab rails, would facilitate greater independence.
· “Assistance” means “transfer.” Assistance required was more involved than pushing or rotating a wheelchair; the majority of residents receive transfer assistance that often requires two staff members and a mechanical lift.
· Device use by residents is different than that depicted in ADA examples. At Parker, 92 percent of skilled nursing residents use mobility devices, 80 percent being wheelchairs. ADA-compliant bathroom designs don’t incorporate realistic placement of these devices during transfer on or off the toilet or during use of the toilet, hand washing, personal grooming, and showering.
Setting the goals
Setting out on a mission, Parker assembled a team of experts—including Parker President and CEO Roberto Muñiz, Parker managers and direct caregivers, architects from Spiezle Architectural Group (Trenton, N.J.), and environmental gerontologist Lorraine Hiatt. There was one primary goal: to design a fully accessible bathroom capable of serving a range of users and equipment, including:
· Residents transferring with different degrees of assistance and using various combinations of devices
· Residents with changing capabilities that occur with age-related disabilities (e.g., balance loss with increased progression of dementia)
· One or two staff members providing assistance
· Assistive equipment used during toileting, handwashing, and showering
· Residents and staff requiring movement of their upper and lower body.
For residents, desired outcomes included:
· Increased toilet use
· Decreased episodes of incontinence and skin breakdown
· Comfortable toilet mounting and dismounting
· Safer transfer
· Reduced bathroom falls
· Increased shower safety
· Improved compliance with handwashing
· Enhanced resident dignity
· Improved environment with flushed waste versus use of incontinence products.
Finally, for caregivers, the anticipated results included:
· Enabling capable residents to facilitate their own transfer, thereby reducing lifting
· Incorporating design features and space that allow staff (and residents) to maintain balance
· Providing safer transfer, wheeling, and repositioning as well as shower use
· Improving confidence in personal safety to encourage better caregiving
· Streamlining toileting to improve options for other personal and cognitive care.
Plan in action
The team conceived a plan to accomplish these goals. It involved taking a fresh look at every detail—from the size and configuration of the bathroom to the placement and attributes of the toilet and shower, location and sizes of doors, and type of doors (swing vs. slide)—all with a focus on maneuverability with walkers, wheelchairs, and lifts for both residents and their caregivers.
The resulting configuration exceeded ADA code. The most significant changes involved moving the toilet away from the wall so two caregivers can assist a resident at one time. This also required the installation of grab bars on both sides of the toilet, instead of on just one side, and in the rear, providing residents with increased support. The bathroom was enlarged to accommodate a 5-foot-6-inch turning radius, an increase over the standard 5-foot code requirement, to allow for easier three-point turns with caregivers and access to the shower, toilet, and sink.
To evaluate the proposed design pre-construction, it was taped out in the basement of another Parker home. When the architects and staff members tested the layout, they discovered the need for several additional changes. These included widening the door and relocating it for better access to the bathroom, confirming the sink location and completing full turning movements—with and without assistance—within the bathroom.
Next, the team built an actual mock-up of the bathroom. Here, architects, staff—and now residents—tested the details. Could a resident open and close the door? Could he or she reach the grab bars? Could a smaller resident reach the sink as well as the controls for the water? Was there enough leg room under the sink for a larger resident in a wheelchair? Were the shower controls in the most convenient location? This study resulted in some important modifications such as adjusting the locations of nearly all toilet accessories (toilet paper, paper towels, soap dispensers, etc.), moving the shower controls, and changing the shower rod from straight to curved.
Positive results from that exercise brought the team to requesting an ADA variation from the DCA. The variation called for the two-sided fold-up grab rails, which meet minimum code-required weight-bearing requirements, located on both sides of the toilet at 18 inches off of the center line of the toilet. Relocating the toilet 36 inches from the side wall accommodates the grab bars—and provides caregivers with access to residents from both sides of the toilet, a 200 percent increase in accessibility.
Parker also requested that shower dimensions be adjusted to improve wheelchair and shower chair (versus bench) assistance for in-room showers. Code requirements call for a 3-by-3-foot square configuration. At PAM, the back wall of the shower has been increased to 3 feet 2 inches, and the front opening was widened to 4 feet 6 inches. These size improvements—as well as the trapezoidal shape—are designed to increase resident safety (wet floors, falls) and staff safety (safe handling) by keeping water in the wet zone and out of the remainder of the bathroom, the dry zone.
The floor design and depth are also sized and shaped for a safer “foot work” area for staff and residents. A caregiver can stand in a safe-handling position on a dry floor while the resident is seated in a movable shower chair with arm rests in the wet zone. This is an improvement over standard showers that feature an armless bench and typically face the resident in only one direction, compromising assistance and safe procedures before, during, and following a shower. At PAM, after showering, a resident can be dried and prepared for a safer transfer onto dry floor. (See sidebar for more details on the resulting design.)
Despite the fact that the adjusted designs exceeded ADA regulations, they didn’t meet New Jersey’s specific accessibility guidelines and were initially rejected. Determined to gain acceptance, the Parker team mobilized. Hiatt wrote a brief detailing Parker’s position that was submitted to the DCA. Next, representatives from Parker, Spiezle, and Hiatt met with officials from the DCA Bureau of Construction. The case for bathroom modifications was made, complete with data and research findings. At that meeting, a design waiver was granted, and all design variations have since been incorporated at PAM and will ultimately be introduced to all Parker facilities.
To assess the effect of these design modifications—as well as the overall effect of adopting the household model of care—PAM is conducting a research study with the LeadingAge Center for Applied Research. While the results of the multiyear study won’t be available for some time, initial reactions from PAM residents and staff support the changes and confirm that bathroom design and toilet placement really does matter.
Steve Leone, AIA, LEED AP BD+C, is principal at Spiezle Architectural Group (Trenton, N.J.). He can be reached at firstname.lastname@example.org.
At Parker at Monroe, the size and shape of the bathrooms accommodate patterns of actual use, including necessary devices, as well as the safety of residents and caregivers with the following features:
· Access on both sides of the toilet was provided by locating the toilets 30 inches from the wall.
· Floor space allows for 5-foot-6-inch turning.
· Improved entryways with wide, barn (sliding) doors enable staff to assist or push residents in wheelchairs into the bathroom, close the door, and move around both sides of the wheelchair.
· Grab bars were located for safe use by residents during self-transfer, steadying, and maintaining upright positioning. The two-sided rails are carefully spaced for stand-to-sit and sit-to-stand body mechanics.
· The unique shape of the fold-up rail accommodates stand-up and seated use. When folded down, rails provide superior positioning for residents’ use, particularly helpful in steadying during seating and standing. In the fold-up position, it’s much easier for residents to reach than a single horizontal back toilet bar.
· The shower is designed for maximum safety. The shape and use of a movable shower chair streamlines showering and resolves the safety hazards of standing on wet surfaces. The entry and shower drain are designed to direct water flow to the back of the shower, away from the entry.