Guest Columns

Can your building prevent falls?

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Michael Hass
Michael Hass

As a development, design, and construction professional, I have a generous and healthy respect for the fact that the buildings we build are entirely secondary to the care provided inside them. In many ways, the building can only hinder the delivery of care by creating obstacles or complications to the daily routines of resident-facing staff. After 20 years of working in the seniors industry, I'm well aware that falls are a devastating (but preventable) health risk. Some estimates are that 1,800 elders die each year from falls and that around 5% of falls result in fractures that can be permanently disabling.

The front line of fall prevention is absolutely in the care plans, resident health, and daily routines of our buildings. In a secondary role, on the physical infrastructure side, we think of preventing falls this way: No steps, no loose rugs, and no storage in the corridor. These are elements we avoid in our buildings so that we don't cause falls. But what if the building could actually help prevent falls?

The building can't do much for resident strength, gait control, medication response, or wheelchair maintenance. But there are places where the building can help.

The first place we look for fall prevention design strategies is the “hot spots” for falls. For example, many falls occur during transfers, so building in elements like grab bars around toilets or patient lift devices are obvious. Looking deeper in transfer-related falls, we have found that bed height (usually too high) can be a major contributor. Staff can be trained to set the bed height correctly but what if the building could help them remember or to know what “correctly” means? In several recent projects, we've deliberately installed a fixed device such as a switch, power outlet, nurse call cord, or artwork at a height in the room that staff can visually reference against the bed height (note: check ADA requirements and your facility's beds). This way there can be an easy check for bed height before the transfer begins.

For transfers to a toilet, we like to put a “knee” wall (a wall roughly the height of the vanity) between the toilet and the vanity so aides or even the resident has a something firm to lean against. Vanity tops can be slippery when wet. Minimizing the distance from the bed to the toilet is also wise. Perhaps most powerfully, we see less falls in communities where the toilet is next to the door rather than across the bathroom from it. This way the resident can enter the room and back onto the toilet (with or without assistance) without a 90 or 180 degree turn. Lastly, the more you can center the toilet in the bathroom, the more able you are to have an aide on either side of the toilet which dramatically reduces the risk of transfer falls.

Also related to the bathroom, we know that visual impairment can lead to falls as well.  We like design with increased contrast in the bathroom, with a darker floor, a white toilet, and a dark toilet seat. With ARMD or cataracts, this contrast makes the “target” more visible. In fact, we generally try to mark major changes with high-contrast visuals. This could be flooring material transitions, elevation changes if you absolutely have to them, or even to mark areas residents shouldn't be going.

Night lights are common practice and even a code requirement in many places. However, not enough attention is paid to the light itself and its placement. We prefer to place the light in a way that illuminates the toilet but also minimizes shadows on the floor. Shadows are disorienting and can obscure an obstacle on the floor. Even if it requires two lights (it usually does not) try to light the entire path from the bed to the toilet without too much illumination on the sleeping resident.

Similarly, glare can be distracting or even blinding to aging eyes, so we encourage the use of honed countertops instead of polished. This makes the edge of a vanity top more distinct and has the added benefit of making small toiletry items easier to spot on the counter. Older eyes take longer to adjust to changes in lighting levels, so we require our lighting designers to prepare photometric studies of the entire building to, in part, look for places where levels would change abruptly on a path of resident travel.

With flooring, we put a lot of effort into keeping flooring materials consistent throughout the resident environment. It's so common to have carpet in a corridor and vinyl in a resident room but that transition then occurs at the door threshold which happens to be the worst place for it. Instead we're moving more and more to flooring layouts that either eliminate changes in materials or move it out to the corridor where we can mark it distinctly with a pattern and color change and also allow the resident more room to navigate it as they feel comfortable.

Finally, I would note that we see anecdotal evidence that complex patterns in flooring can disorient residents, especially residents who ambulate leaned over and looking at the floor. A simpler, more subtle pattern is less likely to create vertigo or magnify floaters as the resident moves over it.

Working through these ideas with design professionals is a great idea and some are easier to implement than others. But putting infrastructure in support of fall prevention is too important not to emphasize.

Michael Hass is a Managing Partner at Drive DP in Arizona.


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Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.