As a geriatric nurse aide, Harriett Jones has spent the last 36 years calmly steering her residents through shower time, keeping plenty of warm towels handy or singing to soothe an anxious bather.

While she maintains eye contact throughout the process, Jones also keeps an eye on safety in the spa room.

Given an increasingly ambulatory population, the presence of water and the kind of warm and moist environment that invites bacteria to breed, risk is inherent in skilled nursing bathing areas. 

It takes careful strategy, attention to detail and smart use of equipment to deliver a sanitary and satisfying bath while preventing accidents that could leave residents or staff injured.

At Levindale Hebrew Hospital and Nursing Center in Baltimore, Jones’ job is made easier because staff pair up for every single transfer, whether they’re using a Hoyer lift to get someone from bed to a shared bathing area or doing a slide transfer to a shower bed.  

“It’s not really a hard part of the job,” says Jones, who works the evening shift on Levindale’s Golden Hill unit, home to about 50 residents. “I feel wonderful that I can do this for them. We always talk to them, talk them through the shower, which part of the body we’re cleaning, asking them if it’s OK to move on.”

About 80% of falls among seniors happen in bathrooms, according to the National Institute on Aging. In the community, one-third to one-half of those falls are blamed on environmental factors like poor lighting or uneven surfaces.

But even in nursing homes that control for those variables, danger can suddenly appear in places it never has before — or in patients who’ve always seemed ready and willing to take a shower.

Some residents may become agitated due to dementia or other cognitive impairment, and conditions ranging from diabetes to a new hypertension medication could increase fall risk overnight.

“Bathing safety requires good communication between the nurse and her CNAs,” says Jacqui Moran, RN, nurse account manager for education and compliance for Guardian Pharmacy in Southeast Florida.

She recommends shifts begin with a review of any new fall risks, and that the right transfer tools and safety equipment be used even if a resident appears steady.

“Make sure you’re using your gait belt or their walker,” Moran says. “And CNAs need to know that the path is clear. You are that resident’s eyes and ears. Never turn your back. That one moment is when someone can slip and fall.”

Super-vision

For most of nursing home residents, a shower takes place in a shower chair. And the vast majority of those are made of inexpensive medical grade PVC piping with relatively low weight limits and short life spans.

Supervision is essential, as is use of safety features such as lap belts and brakes. It’s also important to understand how shower chairs will work on different surfaces.

In a recent column for
McKnight’s Senior Living, Lisa B. Bixler says chairs pitched too steeply toward a central shower drain could “twist a person’s legs to the point of collapse, even while being used ‘properly.’” 

And if a resident attempts to stand from a lightweight chair while holding a grab bar, the seat could tip as the weight is removed. She recommends strip drains for facilities using those chairs.

Drains should flow freely so excess water doesn’t pool at residents’ or staff members’ feet. Staff members also should be wearing non-skid shoes.

As a secondary technique of preventing water from leaving the shower area, Levindale aides roll resident chairs onto oversized, flat towels, catching any water dripping from a residents’ hair or elsewhere before they head back to their bedroom.

A shower chair also allows nursing aides to extend a resident’s legs or tilt the resident back.

Others may be whisked to the shower room on a shower table, which allows for a side-to-side transfer and disrobing in bed, instead of in the shower room.

“I’m often confused as to why we don’t see more of those,” says Len Sears, director of sales for Lopital by ProCare Medical. “The shower table is the easiest way to shower and to transfer.”

Levindale residents who are most at risk of falling in the shower use shower tables. Jones says these are typically people who have poor core strength and are unable to remain upright in the shower chair even with the use of a safety strap.

No matter what, the resident’s bathing preference should be documented on admission, quarterly and with a change in condition, experts remind. Finding the right method often requires talking to the resident and understanding his or her specific wants and needs. Having two sets of hands available at all times — and a built-in safety call button at the shower side — helps Jones and her staff feel secure. 

In settings that don’t require multiple staff for showering, Moran says aides shouldn’t try to reach out a hand to catch a tumbling resident.

“Often, if someone goes down, you’re inclined to reach out and catch them, but they’ll take you down, too,” she says. “It’s better to get close and ease them down.”

Staff protection

ProCare introduced its Lopital line to the U.S about nine years ago after it proved popular in the Netherlands. The battery-operated chairs can provide tilt, height adjustment and/or seat widths and weight limits designed for bariatric residents.

The height-adjustable chairs, in particular, are ergonomically designed and help reduce caregiver strain. They also can put resident and caregiver eye-to-eye during the entire bathing process.

While Sears says his products are gaining traction in Veterans’ Affairs facilities and in some faith-based communities, he admits that operators may still find the upfront cost of a $6,500 shower chair daunting.

But he expects that over the next few years more facilities will invest in durable equipment because it makes the bathing process easier for residents and caregivers, improves clinical outcomes and cuts down on cross-contamination.

“There is buy-in now to using motorized devices on the appropriate residents who need it,” Sears says, noting the almost wholesale migration to power lifts. “In the past, there was a lot more manual lifting, and it was arduous work.”

Making the process easier on staff may mean they do a better job. For instance, using a shower chair that raises a resident as high as 44 inches will reduce the potential for back strain and encourage a CNA to do a more thorough job on foot care. The same holds true for the frequently uncomfortable task of pericare, which is often performed while the CNA is on his or her knees.

“If you give the caregiver better access, that’s better pericare. And better pericare means better quality of life,” Sears says. “It’s not just a difference. It’s a profound difference.”

Healthcare bathing units featuring whirlpool action are also a good option for skilled nursing facilities. They can deliver a home-like and unique cleaning experience.

“The more submerged the body is, the cleaner the body gets,” explains Lee Penner, founder of Penner Bathing Spas. “They get clean by cavitation, a bubble in the water that explodes or breaks against the body and creates a vacuum that pulls dead skin and dirt away.” 

Disinfection station

Penner says his system works better than a plumbed whirlpool because it doesn’t circulate that dirty water with a motor. Water enters through one line, more water is added through another and water is drained out by another at the end of the bath.

That means fewer twists and turns where bacteria may hide from even the best sanitizers.Penner sells its own sanitizing solution, but any quaternary formula will do as long as it is used according to directions.

Lopital chairs also come with wall-mounted disinfection cabinets, to reduce contamination associated with undiagnosed C. diff or other infections.

“The infection prevention issue is much larger now in the Rules of Participation and because of QAPI,” Sears says. 

“Not only do you have the infection concern, but many of these residents are incontinent and have episodes while the chair is being used.”

Where possible, look for shower equipment made of smooth bent metal, which has fewer nooks and crannies where bacteria or mold could form. Likewise for mesh designs — those types of equipment may require a longer, hands-on cleaning approach to completely sanitize.

Reducing rates of reportable infection is just one way a safe and pleasant bathing program can impact the bottom line.

“Facilities want for people to tell their friends, ‘The staffers here are really great,” says Guardian Pharmacy’s Moran.