Designing a Better Bathroom

by Patricia A. Maben, RN, MN

During the past six years, I have had the opportunity to work with a number of good architects and members of SAGE. These individuals have shared many ideas and concepts that have enriched my knowledge and ability to provide consultation to companies building and remodeling health-care facilities in Kansas.

The Toilet Room
The toilet room is an area of design that generally has not been emphasized in new construction and remodeling of long-term care facilities. Because good toilet-room design can prevent excess disability in elders, and because many elders need assistance with transfer before and after toileting, the placement of the toilet makes a significant difference in safety for both residents and staff.

The design of toilet rooms in nursing and assisted living facilities is usually driven by the examples provided in the Americans with Disabilities Act (ADA) Accessibility Guidelines. The design examples illustrated in these guidelines are intended for persons who do not need physical assistance in transferring on and off the toilet. Individuals with good upper-body strength can use the grab bars for transfer, but most elders, especially older women, do not have good upper-body strength and cannot effectively use the grab bars in the standard position.

Another problem I often see is that the toilet is too close to the wall (typically within 18″) for residents who need staff assistance with toileting. This small space does not allow for easy and safe transfer.

In Kansas, staff from the licensing agency met with staff of the attorney general’s office responsible for ADA enforcement. The agency was in the proc-ess of amending regulations and asked for a review of proposed changes to ensure ADA compliance. The discussion led to a review of subsection 2.2 of the ADA guidelines, which provides for “equivalent facilitation” of the guidelines. The subsection reads as follows:

2.2 Equivalent Facilitation. Departures from particular technical and scoping requirements of this guideline by the use of other designs and technologies are permitted where the alternative designs and technologies used will provide substantially equivalent or greater access to and usability of the facility.

This provision in the law provides the opportunity for architects and owners to explore alternative designs that can better meet elders’ needs.

During the past seven years there has been a significant increase in new construction and remodeling of nursing and assisted living facilities in Kansas. Owners and architects are encouraged to meet with staff of the licensing agency early in the process. The Kansas Department of Health and Environment no longer has a licensed architect on staff to review and approve architectural drawings. Instead, the department’s Long Term Care Program staff review plans for compliance. The project’s architect is required to certify that the architectural drawings are in compliance with the appropriate regulations prior to beginning construction.

Reviewing plans early in the process has been very productive. This allows both providers and architects to dialogue with licensing staff about their “dreams” for the new facility. It is also a time to review the regulations and deal with “myth” regulations that have often limited good design.

Every state has these “myth” regulations. For example, during a tour of a new, innovative facility, an administrator from another facility asked why we (the “state”) had not required the new facility to have a door on the soiled utility room. I told him there was no requirement for a door and pointed out that in most facilities, the door to a soiled utility room remains open most of the time. It is important that architects and owners read the construction regulations carefully and, when in doubt, contact someone at the licensing agency.

The design elements reviewed for a toilet room include the following: door and door swing, position of toilet, grab bars, lavatory and mirror placement, storage, shower, and use of color and lighting. If the components of the toilet room are correctly designed, the elder will have greater opportunity to be as independent as practicable, and assistance provided by staff will be safer for both parties.

In nursing facilities, because of the high number of residents who will need assistance transferring on and off the toilet, it should be placed so that a staff person can stand on either side of the resident. Fold-down handrails or grab bars that can be moved away from the toilet allow staff easier access. The toilet also should be located so that a mechanical lift device can be moved through the doorway to the toilet without having to make a 90-degree turn. Correct placement of the toilet can lessen resident falls and should decrease staff injuries.

If the toilet is 18″ from a wall, an angled grab bar is more useful for residents than the standard horizontal bar, particularly for women, who are generally shorter and have less upper-body strength than men. For most of these individuals, the horizontal grab bar is essentially useless. Being able to grasp an angled grab bar at the lower position and move up the bar can increase transfer independence.

Older adults seldom use the horizontal bar over the tank, as called for in the ADA guidelines. In all my years in long-term care, the only use of this grab bar I have noted has been as a towel rack. This position also makes it difficult to access the toilet tank and often forces facilities into using flush-valve toilets, which present other problems. For example, most residents are familiar with the standard tank design, and they are used to being able to lean back into the toilet seat lid that is supported by the tank. Flush-valve toilets usually do not have a toilet seat lid. If a resident decides to lean backwards, there is no support, and he or she might fall. If a flush-valve toilet must be used, a toilet seat with a lid might help compensate for the lack of a tank.

The height of a toilet also can make a difference in both safety and in the ability to physiologically use the toilet. For many years, nursing facilities installed toilets with a height of 24″. This was known as a “handicapped” toilet. Section A4.16.3 of the ADA guidelines states that “height preferences vary considerably among disabled people. Higher seat heights may be an advantage to some ambulatory disabled people, but are often a disadvantage for wheelchair users and others. Toilet seats 18 in (455 mm) high seem to be a reasonable compromise. Thick seats and filler rings are available to adapt standard fixtures to these requirements.”

A “handicapped” toilet will not allow older women who are less than 5’5″ tall to place their feet on the floor. This causes sitting instability, which can lead to falls. In addition, being unable to have their feet flat on the floor or not having their hips at or below knee height does not facilitate the emptying of the bladder or evacuation of the bowel. Toilet seats with varying heights can be used to accommodate different needs, as mentioned in the ADA guidelines. A person with a recently fractured hip must maintain a sitting position with the hips higher than the knees. This individual may need a seat riser to meet his or her needs during the healing process. Therefore, being able to vary the height of a toilet seat is very important.

The use of color in the toilet room is also important. There should be color contrast between the floor and toilet, and between the countertop and the floor. Unfortunately, many toilet rooms are predominantly white. A resident with poor color discrimination will have difficulty locating the white seat of a toilet if the flooring is white or a light color, which can lead to falls. Male residents will have difficulty voiding into a toilet while standing if there isn’t significant color differentiation between the toilet and the flooring. Vinyl flooring is now available in nonslip surfaces, and some are available with a padded foundation to minimize fractures in the event a resident does fall.

In the September 2002 newsletter from SAGE, there is an excellent article entitled “Code Toilet or Not Code Toilet: That Is the Question” by Jon Sanford, a research architect with the Rehab R & D Center, Atlanta Veterans Administration, in Decatur, Georgia. Sanford discusses the ADA Accessibility Guidelines and the need for alternative designs for elders. [Note: A copy of this article can be requested from SAGE by e-mailing SAGE@hotmail.com or by calling (440) 256-1880 and requesting a copy of the September 2002 newsletter.]

The Lavatory Area
Accessibility to the lavatory, or sink, area of the bathroom is important in assisting residents to remain independent in grooming. The lavatory should be accessible by residents in wheelchairs. This can be accomplished by having space under the bowl or providing for side access. It should also be noted that single-control faucets can be difficult to use for residents who have poor grasping ability; blade handles are the easiest style for most elders to grasp.

Mirrors should be located low enough to allow residents in wheelchairs to see their reflections. This usually means that the mirror extends to the upper edge of the lavatory or vanity top. A drawer located in the vanity top allows an elder who uses a wheelchair to access storage for grooming items.

Bathroom Doors
Doors that slide into a wall pocket (“pocket doors”) or “barn”-style doors with exterior tracks have been used with increasing frequency in toilet rooms. Newer-style hardware for pocket doors allows persons with a poor grasp to be able to open and close them with little effort. Doors that open out into the room often swing into the same area as the entrance door to the unit and/or the door to a closet. Having two or more doors swinging into a single space has been shown to increase resident falls and should be avoided.

The location of the toilet room door is important for cueing and privacy. The toilet should be in the resident’s line of sight while he or she is in bed. This cueing will help residents remain continent longer. For privacy, the toilet room should not be visible from the hallway or entrance to the room or unit. Exterior windows should not be in the straight line of sight with the toilet room.

The Shower Area
Shower stalls need to be accessible to residents in wheelchairs. Those that are 60″ wide and have a flexible curb to keep water from flowing out of the shower are probably the most usable for older adults. The flexible curb allows a wheelchair to roll over the entry. Some architects are placing two drains in the shower area to increase flow of wastewater. The additional drain can prevent water from flowing over the low curb onto the bathroom floor.

Shower stalls that are 36″ X 36″ with a fold-down seat often are not large enough to allow a resident to use a flexible hand-held showerhead while seated. This size opening is also inadequate for a resident who uses a wheelchair to transfer into the shower area.

A few facilities in Kansas have used the “European” open shower design, in which the entire room becomes the shower. The walls and flooring are water-resistant, and the floor slopes to the drain. Residents can shower sitting on a shower chair or, in a small bathroom, while sitting on the toilet seat. This design has been well received by the residents and staff of the facilities.

The Future
The design of nursing homes has changed little in the past 50 years. Most facilities are still built in the hospital model and do not take into consideration the unique needs of older adults. The emphasis following the passage of the Nursing Home Reform Act in 1987 has been on providing “homelike” environments. In addition, the act emphasizes the need to provide care and services that assist residents in reaching their highest possible level of independence. To reach this public-policy goal, a significant change in the design of bathrooms is needed.

A partnership needs to be created between regulators and the long-term care industry in developing and amending regulations that support the movement to more resident-enabling environments. Maintaining rigid, specific regulations based on what was considered a hospital model 40 to 50 years ago will limit facilities’ and architects’ ability to create these needed environmental changes. The current Guidelines for Design and Construction of Hospitals and Health Care Facilities, published by the American Institute of Architects Academy of Architecture for Health, support the comments made in this article.

In some instances, local officials have questioned designs approved by the state licensing agency. The local building inspectors expect the bathrooms and toilet rooms to look like the designs found in the ADA guidelines. Architects in Kansas know they can call the licensing agency for assistance in working through these differences with local officials regarding ADA requirements. This process has been beneficial to all parties.

In Kansas the licensing agency is collaborating with SAGE Kansas in developing outcome-based regulations for nursing facilities. These regulations will focus less on specific requirements and more on what should happen in relation to the resident and staff. For instance, instead of requiring specific square footage in a toilet room, the regulation will require that the shower, toilet, and lavatory be accessible to a person with disabilities. Eventually, the same process will be used for all types of residential facilities licensed by the agency. Hopefully, this process will encourage owners and architects to be more cognizant of research findings regarding the effect of the environment on outcomes of care for the populations they serve. Cooperation between regulators and providers can only result in positive outcomes for residents. NH

Suggested Reading
The American Institute of Architects. Guidelines for Design and Construction of Hospital and Health Care Facilities, 2001. The American Institute of Architects Academy of Architecture for Health, Washington D.C.
Sanford J. Code toilet or not code toilet: That is the question. Society for the Advancement of Gerontological Environments. Vol. 2, Issue 2, September 2002.
U.S. Architectural & Transportation Barriers Compliance Board. Americans with Disabilities Act Accessibility Guidelines. Published in the Federal Register July 26, 1991. Washington, D.C.