1
Resident Safety Risk Assessment
Summary of L iter ature re v ie w
funding provided by a grant from
The hulda B. & Maurice l. roThschild FoundaTion
pubLiShed by
The cenTer For healTh design
www.healthdesign.org
By
anjali Joseph, Phd, edac
Xiaobo Quan, Phd, edac
JulY 2012
abstract v
resident Safety risk assessment
iacknowledgements |
resident Safety risk assessment
Acknowledgements
The Rothschild Foundation is a national private philanthropy with a primary
interest in improving the quality of life for elders around the country, in long-
term care communitiies. Currently, the Foundation is supporting the development
of alternative long-term care programs and built environment designs, as well as
regulatory change.
The Center for Health Design (CHD) is a nonprofit organization that engages and
supports professionals and organizations in the healthcare, construction, and design
industry to improve the quality of healthcare facilities and create new environments
for healthy aging. CHD's mission is to transform healthcare environments for a
healthier, safer world through design research, education, and advocacy.
The hulda B. & Maurice l. rothschild Foundation
The center for health design
abstract v
resident Safety risk assessment
iitable of Contents |
acknowledgements ................................................................................. i
i. summary of literature review ............................................................... 1
ii. Purpose ................................................................................................... 3
iii. Methodology ............................................................................................ 4
iV. results ..................................................................................................... 5
Resident Falls .......................................................................................................... 5
Resident Elopement/Unsafe Exiting ....................................................................... 5
Sleep Disorders ....................................................................................................... 6
Aggressive/Disruptive Behaviors ............................................................................. 6
Medical Errors ......................................................................................................... 7
Healthcare-Associated Infections ........................................................................... 8
Resident Safety Risk Assessment Matrix ............................................................... 9
V. conclusion ............................................................................................... 18
Vi. references ............................................................................................... 19
Vii. author Biographies .................................................................................. 26
Anjali Joseph, PhD, EDAC .................................................................................... 26
Xiaobo Quan, PhD, EDAC ...................................................................................... 26
Table of Contents
resident Safety risk assessment
abstract v
resident Safety risk assessment
1Summary of Literature review |
The purpose of the literature review was to create a framework for evaluating key
environmental design features that impact resident safety in various residential care
settings—skilled nursing facilities, assisted living, and memory-care facilities. The
review focused on the existing empirical research studies about the relationships
between environmental design and safety outcomes in residential care settings. After
a process of searching, sorting, and screening over 100 publications, a total of 55
research articles were identified and classified into six major outcome categories. A
framework was then created to present the environmental features impacting each
outcome category, key research findings, strength of evidence, and the relevant
reference information as well as evidence-based design recommendations.
The existing body of research evidence indicates that various environmental features
significantly impact safety outcomes in six categories:
Resident falls•
Resident elopement/unsafe exiting•
Sleep disorders•
Aggressions/disruptive behaviors•
Medical errors, and•
Healthcare-associated infections•
Several environmental features are especially important because each of them
influences multiple resident safety outcomes:
Room occupancy (single-bed rooms) •
Lighting (high lighting level, sunlight) •
Outdoor nature/wander garden•
resident Safety risk assessment
abstract
I. Summary of Literature Review
abstract v
resident Safety risk assessment
2Summary of Literature review |
Acoustics (noise reduction, music, nature sounds)•
Ambience (soothing environment, positive distractions).•
The literature review also identified several gaps in knowledge base that need more
research. Rigorous research is needed to verify whether evidence from other similar
healthcare settings including other residential care settings is also applicable in specific
residential care settings and to address specific problems found in residential care.
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resident Safety risk assessment
3purpose |
II. Purpose
The purpose of the literature review was to create a framework/matrix that outlines
the safety issues that should be considered in the design of various long-term care
(LTC) settings (skilled nursing homes, assisted living, and dementia/Alzheimer’s
care facilities). This matrix will help to guide the development of the Resident Safety
Risk Assessment (RSRA) to be submitted as a proposal for the 2014 Guidelines for
Design and Construction of Health Care Facilities.
The objective was that the RSRA matrix would serve as a broad evaluation
framework for the key design areas (e.g., noise, light levels, design of outdoor spaces)
that impact resident safety in various residential care settings—skilled nursing
facilities, assisted living, and memory-care facilities. Serving as the basis for the
RSRA, the literature review was conducted to identify existing research studies that
empirically examined the relationship between design and safety outcomes in LTC
settings. In addition, the literature review was to identify areas in the RSRA where
additional research may be needed to strengthen guidelines language for future
revision cycles.
resident Safety risk assessment
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resident Safety risk assessment
4methodology |
III. Methodology
resident Safety risk assessment
A literature search was conducted on The Center for Health Design (CHD)
database of evidence based design literature, PubMed, EBSCO, and other databases
such as Google Scholar. Additional literature was also obtained from several existing
literature reviews on relevant topics (e.g., Chang et al., 2004; Day, Carreon, &
Stump, 2000; Joseph, 2006) and the reference lists of the identified publications. In
the second step, the more than 100 publications found in the first step were sorted,
screened, and narrowed down to about 55 publications that empirically supported
the connection between the physical environment and resident safety outcomes in
LTC. The vast majority of the identified research was conducted in LTC settings.
However, relevant research conducted in homes of seniors as well as other similar
healthcare settings was also included for certain topics lacking empirical research in
LTC settings.
In the third step, the identified literature was first sorted according to the outcome
categories (e.g., resident falls). Then the environmental features (e.g., wander garden)
impacting each safety outcome category were identified. Information regarding
the relationships between safety outcomes and environmental factors was extracted
from the literature. A RSRA matrix (see attached) was established based on the
literature review. Each row of the matrix presents the relevant information, including
research settings, key research findings, strength of evidence, and literature reference
information, for the relationship between one outcome and one environmental
feature (e.g., resident falls—wander garden).
Design recommendations based on the research evidence were also provided.
The strength of evidence was rated as 1 or 2: 1 meaning that the relationship
was supported by only one or two studies with a weak study design/measurement
tool or only nonsignificant tendencies were found in the research; 2 meaning that
the relationship was supported by multiple studies with a strong study design/
measurement tool and significant results from statistical analyses.
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resident Safety risk assessment
5results |
IV. Results
The review identified six categories of safety outcomes (i.e., resident falls, resident
elopement/unsafe exiting, sleep disorders, aggressions/disruptive behaviors,
medical errors, and healthcare-associated infections) that were impacted by various
environmental features. This section summarizes key findings in these six outcome
categories. (See the RSRA matrix on page 7 for details.)
Environmental design can effectively reduce resident fall risk by increasing ambient
lighting levels (Creditor, 1993; McMurdo, Millar, & Daly, 2000; Vu, Weintraub, &
Rubenstein, 2004), reducing light glare (Bicket et al., 2010), reducing the use of physical
restraints including bedrails (Capezuti, Strumpf, Evans, Grisso, & Maislin, 1998;
Hoffman, Powell-Cope, MacClellan, & Bero, 2003; Si, Neufeld, & Dunbar, 1999),
positioning beds to prevent resident falling from bed (Hofmann, Bankes, Javed, & Selhat,
2003), selecting low-height beds or chairs (Scandura, 1995), and selecting soft (e.g.,
wooden) subfloor and flooring with small motifs and lowest contrast (Perritt, McCune,
& McCune, 2005; Simpson, Lamb, Roberts, Gardner, & Evans, 2004). In addition,
a wander garden may reduce the frequency and severity of falls of demented residents
(Detweiler, Murphy, Kim, Myers, & Ashai, 2009). Research conducted in homes of
seniors suggests that optimizing configuration of grab bars near bath/toilet may reduce
falls related to the use of bathtubs and toilets (Runyan et al., 2005; Sanford, Arch, &
Megrew, 1995; Sveistrup, Lockett, Edwards, & Aminzadeh, 2006). More research is
needed to examine the effects of bathroom locations and grab bars in LTC settings.
Unsafe exiting is a special problem in LTC, especially for residents with dementia.
Research found that nursing home residents exhibited fewer unsafe exiting behaviors
in an environment that is soothing and provides appropriate sensory stimulation
such as nature scene artwork, plants, nature sounds, music, and aroma (Algase,
Beattie, Antonakos, Beel-Bates, & Yao, 2010; Cohen-Mansfield & Werner, 1998a).
resident Safety risk assessment
resident Falls
resident elopement/unsafe exiting
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resident Safety risk assessment
6results |
Another effective environmental measure in reducing unsafe exiting or exit-seeking
behaviors is the use of visual barriers to reduce the visibility of exit doors and
doorknobs. The visual barriers can be cloth panels covering doorknobs, window
blinds blocking views of outside, wall mural painted over exit doors, and full-length
mirrors in front of doors (Dickinson & McLain-Kark, 1996; Dickinson, McLain-
Kark, & Marshall-Baker, 1995; Kincaid & Peacock, 2003; Mayer & Darby, 1991).
Research also shows that wander gardens help to reduce aggressive behavior among
dementia residents (Detweiler, Murphy, Myers, & Kim, 2008). Providing safe exits
and transitions from residential areas to wander gardens might help to reduce exit-
seeking behavior or provide a safe outlet to do so.
Sleep disorders are a frequently seen problem in LTC settings that may lead to falls,
delirium, morbidity, and mortality. Higher lighting levels during daytime, bright
light exposure, and sunlight exposure can significantly improve nighttime sleep
(decreased awakenings) and reduce daytime sleep (Alessi et al., 2005; Fetveit &
Bjorvatn, 2004; Satlin, Volicer, Ross, Herz, & Campbell, 1992; Shochat, Martin,
Marler, & Ancoli-Israel, 2000; Sloane et al., 2005; Van Someren, Kessler, Mirmiran,
& Swaab, 1997; Wallace-Guy et al., 2002).
Another effective measure is the reduction of environmental disturbances during
nighttime such as noise and variation of lighting levels (Schnelle et al., 1998; Schnelle,
Alessi, al-Samarrai, Fricker, & Ouslander, 1999; Webber, Martin, Alessi, Josephson, &
Harker, 2004). Disruption from roommates is a significant source of sleep disturbance.
Single-bed rooms may lead to better sleep and less need for sleep medications (Koch,
Haesler, Tiziani, & Wilson, 2006; Morgan & Stewart, 1998a). Access to outdoors may
increase the exposure to bright light and natural elements, therefore, can improve sleep of
nursing home residents with dementia (Calkins, Szmerekovsky, & Biddle, 2007).
Resident agitation and aggressive behaviors may result in harm to residents
themselves, other residents, and staff members. Bright light exposure, increased
environmental lighting, and heightened color contrast have been found to reduce
sleep disorders
aggressive/disruptive Behaviors
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resident Safety risk assessment
7results |
level of agitation and aggression (Koss & Gilmore, 1998; Lovell, Ancoli-Israel,
& Gevirtz, 1995; Sloane et al., 1998). Blocking afternoon sunlight together with
maintaining constant lighting levels may help reduce disruptive behaviors in
individuals with Alzheimer’s disease at senior adult day-care centers (La Garce,
2002; La Garce, 2004).
Agitation and aggression can also be reduced by decreasing spatial and social
density (fewer residents per unit, larger space per resident) and separating
residents by single rooms (Morgan & Stewart, 1998b; Low, Draper, & Brodaty,
2004; Pekkarinen, Sinvervo, Perala, & Elovainio, 2004). Positive distractions
(e.g., visual, audio, and olfactory stimuli of nature or home/people contents,
small-scale homelike environment with features such as residential kitchen
and wander gardens) may help soothe residents, thus reduce psychiatric
difficulties and disruptive behaviors (Burgio, Scilley, Hardin, Hsu, & Yancey,
1996; Cohen-Mansfield & Werner, 1998a; Cohen-Mansfield & Werner,
1998b; Detweiler et al., 2008; Kane, Lum, Cutler, Degenholtz, & Yu, 2007;
McGonagle & Allan, 2002; McMinn & Hinton, 2000; Mooney & Nicell,
1992; Murphy, Miyazaki, Detweiler, & Kim, 2010; Namazi & Johnson, 1992;
Nelson, 1995; Whall et al.,1997).
The literature search did not find environmental research on medical errors that
was conducted in LTC settings. However, research evidence from acute care settings
may shed some light on how environmental design may impact medical errors in
LTC. Especially relevant environmental measures include the increase of lighting
levels and the reduction of environmental distractions and interruptions (unexpected
sounds, unrelated traffic).
These two measures have been found to significantly reduce medication-dispensing
errors (Buchanan, Barker, Gibson, Jiang, & Pearson, 1991; Flynn, Barker, Gibson,
Pearson, Berger, & Smith, 1999; Westbrook et al., 2010). Rigorous research is
needed to verify whether knowledge from other healthcare settings is also applicable
in LTC and address the specific problems in LTC.
Medical errors
abstract v
resident Safety risk assessment
8results |
Research conducted in nursing homes indicated that residents in single-bed rooms
were less likely to contract infections with urinary bacteria (Fryklund, Haeggman,
& Burman, 1997), influenza A (Drinka, Krause, Nest, Goodman, & Gravenstein,
2003), and nonbacterial gastroenteritis (Pegues & Woernle, 1993). In one study,
ratings of the quality of ambient environment (e.g., cleanliness, homelikeness, odors,
and noise) in nursing homes were related to lower risk of hospitalization for infection
(Zimmerman, Gruber-Baldini, Hebel, Sloane, & Magaziner, 2002). Research is
needed to examine the effects of other design strategies (e.g., air filtration, easy-to-
clean materials) on infection control in LTC settings.
One finding of the literature review was that most published environmental
research on resident safety in LTC was conducted in nursing homes or on demented
residents; research on relatively healthier residents in assisted living environments
was very limited. This is consistent with the observation of other researchers (Bicket
et al., 2010). Although it is reasonable to assume that most findings from research
in other LTC settings could be similarly applied to assisted living facilities, research
evidence is needed to directly address special safety issues in assisted living settings.
healthcare-associated infections
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resident Safety risk assessment
9results |
Res
iden
t S
afet
y O
utco
mes
Des
ign
Feat
ures
Key
Fin
ding
sR
efer
ence
sD
esig
n R
ecom
men
datio
ns
Res
iden
t Fa
lls
Visu
al
envi
ronm
ent
(ligh
ting
leve
ls,
cont
rast
sens
itivi
ty)
xx
x- A
mbi
ent
light
ing
leve
l. a
falls
ris
k fa
ctor
asse
ssm
ent/
mod
ifica
tion
prog
ram
incl
udin
g th
e
impr
ovem
ent
of a
mbi
ent
light
ing
leve
l led
to
an
decr
ease
in fa
ll ris
k (n
onsi
gnifi
cant
) (M
cMur
do
et a
l., 2
00
0). h
ighe
r lig
htin
g le
vel w
as r
elat
ed t
o
low
er fa
ll ris
k (V
u et
al.,
20
04)
. li
ght
glar
e w
as
rela
ted
to h
ighe
r ris
k of
fall
(Bic
ket
et a
l., 2
010)
.
- Bic
ket, M
. c
., sa
mus
, Q
. M
., M
cnab
ney,
M.,
ony
ike,
c.
u.,
May
er, l.
s., B
rand
t, J
., et
al.
(201
0).
The
phys
ical
envi
ronm
ent
influ
ence
s ne
urop
sych
iatr
ic s
ympt
oms
and
othe
r
outc
omes
in a
ssis
ted
livin
g re
side
nts.
inte
rnat
iona
l Jou
rnal
of
ger
iatr
ic P
sych
iatr
y, 2
5(1
0),
104
4–1
05
4.
- McM
urdo
, M. e
., M
illar
, a. M
., &
dal
y, F
. (20
00).
a ra
ndom
ized
cont
rolle
d tri
al o
f fal
l pre
vent
ion
stra
tegi
es in
old
peo
ples
’ hom
es.
ger
onto
logy
, 46(
2), 8
3–8
7.
- Vu,
M. Q
., W
eint
raub
, n.,
& r
uben
stei
n, l
. Z. (
2004
). Fa
lls in
the
nurs
ing
hom
e: a
re th
ey p
reve
ntab
le?
Jour
nal o
f the
am
eric
an
Med
ical
dire
ctor
s a
ssoc
iatio
n, 5
(6),
401–
406.
1li
ght g
lare
sho
uld
be
avoi
ded.
am
bien
t lig
htin
g
leve
l sho
uld
be a
bove
the
reco
mm
ende
d va
lues
for
resi
dent
ial b
uild
ings
.
Bed
rails
/
phys
ical
rest
rain
ts
xx
- Ph
ysic
al r
estr
aint
s. P
hysi
cal r
estr
aint
s w
ere
asso
ciat
ed w
ith h
ighe
r fa
ll ra
tes
and
inju
ry r
ates
(cap
ezut
i et
al.,
199
8).
- B
edra
ils. a
fter
a b
edra
il-us
e re
duct
ion
prog
ram
,
incl
udin
g al
tern
ativ
es t
o be
drai
l, su
ch a
s flo
or m
at
next
to
bed
and
full-
leng
th b
ody
pillo
w, be
drai
l use
decr
ease
d as
wel
l as
the
freq
uenc
ies
of fa
lls a
nd
fall-
rela
ted
inju
ries
(non
sign
ifica
nt)
(hof
fman
et
al.,
200
3). B
edra
ils c
an b
e sa
fely
rem
oved
from
mos
t
shor
t-st
ay n
ursi
ng h
ome
reha
bilit
atio
n re
side
nts
(si
et a
l., 1
99
9).
- cap
ezut
i, e.
, str
umpf
, n. e
., ev
ans,
l. K
., g
risso
, J. a
., &
Mai
slin
, g. (
1998
). Th
e re
latio
nshi
p be
twee
n ph
ysic
al re
stra
int
rem
oval
and
falls
and
inju
ries
amon
g nu
rsin
g ho
me
resi
dent
s.
Jour
nals
of g
eron
tolo
gy s
erie
s a:
Bio
logi
cal s
cien
ces
and
Med
ical
sci
ence
s, 5
3(1)
, M47
–52.
- cha
ng, J
. T.,
Mor
ton,
s. c
., ru
bens
tein
, l. Z
., M
ojic
a, W
. a.,
Mag
lione
,
M.,
sutto
rp, M
. J.,
et a
l. (2
004)
. int
erve
ntio
ns fo
r the
pre
vent
ion
of fa
lls
in o
lder
adu
lts: s
yste
mat
ic re
view
and
met
a-an
alys
is of
rand
omize
d
clini
cal t
rials.
Brit
ish M
edic
al J
ourn
al, 3
28(7
441)
, 680
–687
.
- hof
fman
, s.,
Pow
ell-c
ope,
g.,
Mac
clel
lan,
l.,
& B
ero,
K. (
2003
).
Bed
saFe
: a b
ed s
afet
y pr
ojec
t for
frai
l old
er a
dults
. Jou
rnal
of
ger
onto
logi
cal n
ursi
ng, 2
9(11
), 34
–42.
- si,
M.,
neu
feld
, r
. r
., &
dun
bar,
J. (1
99
9).
rem
oval
of
bedr
ails
on
a sh
ort-
term
nur
sing
hom
e re
habi
litat
ion
unit.
The
ger
onto
logi
st, 39
(5),
611–
614.
2r
emov
e be
drai
ls fr
om
skill
ed n
ursi
ng b
eds
unle
ss
requ
ired.
loca
tion
and
desi
gn o
f
furn
iture
x- F
urni
ture
(e.g
., be
d) lo
catio
ns. r
epos
ition
ing
beds
with
one
sid
e to
the
wal
l and
rep
ositi
onin
g fu
rnitu
re
to a
llow
mor
e ro
om fo
r m
aneu
verin
g, t
oget
her
with
sta
ffing
cha
nges
and
res
tora
tive
recr
eatio
nal
prog
ram
s, s
igni
fican
tly r
educ
ed r
esid
ent
falls
and
frac
ture
s re
late
d to
falls
(h
ofm
ann
et a
l., 2
00
3).
- Fu
rnitu
re s
elec
tion.
Fur
nitu
re t
hat
put
resi
dent
s
clos
er t
o th
e gr
ound
(i.e
., fu
tons
, be
an b
ag c
hairs
,
mat
tres
ses
dire
ctly
on
floor
) re
sulte
d in
red
uctio
n
of fa
lls (
scan
dura
, 19
95).
- Mal
one,
e. B
. & d
ellin
ger,
B. a
. (20
11).
Furn
iture
des
ign
feat
ures
and
hea
lthca
re o
utco
mes
. con
cord
, ca:
The
cen
ter f
or
hea
lth d
esig
n.
- gul
wad
i, g
. B. &
cal
kins
, M. P
. (20
08).
The
impa
ct o
f
heal
thca
re e
nviro
nmen
tal d
esig
n on
pat
ient
falls
. con
cord
, ca:
The
cen
ter f
or h
ealth
des
ign.
- hof
man
n, M
. T.,
Ban
kes,
P. F
., Ja
ved,
a.,
& s
elha
t, M
. (20
03).
dec
reas
ing
the
inci
denc
e of
falls
in th
e nu
rsin
g ho
me
in a
cos
t-
cons
ciou
s en
viro
nmen
t: a
pilo
t stu
dy. J
ourn
al o
f am
eric
an
Med
ical
dire
ctor
s a
ssoc
iatio
n, 4
(2),
95–9
7.
- sca
ndur
a, d
. a. (
1995
). Fr
eedo
m a
nd s
afet
y. a
col
orad
o ce
nter
care
s fo
r alz
heim
er’s
patie
nts.
hea
lth P
rogr
ess,
76(
3), 4
4–4
6.
1Th
e ar
rang
emen
t of
furn
iture
sho
uld
allo
w
mor
e ro
om fo
r res
iden
t
man
euve
ring
and
to p
reve
nt fa
lls. T
he
ergo
nom
ics
of fu
rnitu
re
(e.g
., lo
wer
bed
hei
ght)
shou
ld h
elp
redu
ce th
e
likel
ihoo
d of
fall
and
inju
ry.
Skilled Nursing
Assisted Living
Dementia/ Alzheimer’s Care
Strength of Evidence
res
iden
T sa
FeTY
ris
K a
sses
sMen
T M
aTr
iX
abstract v
resident Safety risk assessment
10results |
Res
iden
t S
afet
y O
utco
mes
Des
ign
Feat
ures
Key
Fin
ding
sR
efer
ence
sD
esig
n R
ecom
men
datio
ns
Res
iden
t Fa
lls
han
drai
ls a
nd
grab
bar
s
x- B
ath/
toile
t gr
ab-b
ar c
onfig
urat
ion.
one
bar
shou
ld b
e m
ount
ed o
n th
e he
ad o
f fau
cet
wal
l to
assi
st e
nter
ing/
exiti
ng b
atht
ub;
a ve
rtic
al b
ar fo
r
ente
ring/
exiti
ng;
the
seco
nd h
oriz
onta
l or
angl
ed
bar
to a
ssis
t in
sitt
ing/
stan
ding
from
the
bot
tom
of t
he t
ub s
houl
d be
loca
ted
on t
he b
ack
wal
l of
the
tub;
non
slip
sur
face
s on
the
bat
h fr
ont
and
back
rim
s (s
veis
trup
et
al.,
200
6). so
me
grab
-bar
confi
gura
tions
tha
t w
ere
not
code
-com
plia
nt w
ere
pref
erre
d an
d w
ere
used
mor
e of
ten
(san
ford
et
al.,
1995
).
no
empi
rical
rese
arch
in l
Tc.
- run
yan,
c. W
., Pe
rkis
, d.,
Mar
shal
l, s.
W.,
John
son,
r. M
.,
coy
ne-B
easl
ey, T
., W
alle
r, a.
e.,
et a
l. (2
005)
. uni
nten
tiona
l
inju
ries
in th
e ho
me
in th
e u
nite
d st
ates
: Par
t ii:
Mor
bidi
ty.
amer
ican
Jou
rnal
of P
reve
ntiv
e M
edic
ine,
28(
1), 8
0–8
7.
- san
ford
, J.,
arch
, M.,
& M
egre
w, M
. (19
95).
an e
valu
atio
n
of g
rab
bars
to m
eet t
he n
eeds
of e
lder
ly p
eopl
e. a
ssis
tive
Tech
nolo
gy, 7
(1),
36–4
7.
- sve
istru
p, h
., lo
cket
t, d
., ed
war
ds, n
., &
am
inza
deh,
F. (
2006
).
eval
uatio
n of
bat
h gr
ab b
ar p
lace
men
t for
old
er a
dults
. Tec
hnol
ogy
& d
isab
ility
, 18(
2), 4
5–5
5.
2o
ne b
ar s
houl
d be
mou
nted
on
the
head
of
fauc
et w
all o
f bat
htub
;
a se
cond
hor
izon
tal o
r
angl
ed b
ar s
houl
d be
loca
ted
on th
e ba
ck
wal
l of t
he tu
b; n
onsl
ip
surf
aces
sho
uld
be o
n th
e
bath
fron
t and
bac
k rim
s.
Floo
ring/
floor
ing
desi
gn
Floo
ring
thre
shol
ds
xx
- C
arpe
t te
xtur
e. c
arpe
t pi
le t
extu
re w
as a
ssoc
iate
d
with
slo
wer
wal
king
tim
e (P
errit
t et
al.,
20
05)
.
- C
arpe
t pa
tter
n. c
arpe
t pa
tter
ns t
hat
had
smal
lest
mot
ifs a
nd lo
wes
t co
ntra
st w
ere
asso
ciat
ed w
ith
shor
test
wal
king
tim
e an
d lo
wes
t nu
mbe
r of
inci
dent
s (P
errit
t et
al.,
20
05)
.
- Su
bfloo
r. c
ompa
red
to w
oode
n su
bfloo
r, co
ncre
te
subfl
oor
was
rel
ated
to
a hi
gher
ris
k of
hip
frac
ture
in a
fall
(sim
pson
et
al.,
200
4).
- Per
ritt,
M. r
., M
ccun
e, e
. d.,
& M
ccun
e, s
. l. (
2005
). r
esea
rch
info
rms
desi
gn: e
mpi
rical
find
ings
sug
gest
reco
mm
enda
tions
for c
arpe
t pat
tern
and
text
ure.
alz
heim
er’s
care
Tod
ay, 6
(4),
300
–305
.
- sim
pson
, a. h
., la
mb,
s.,
robe
rts, P
. J.,
gar
dner
, T. n
., &
evan
s, J
.
g.
2av
oid
usin
g hi
gh-p
ile
carp
ets.
use
car
pet w
ith
smal
l mot
ifs/p
atte
rns
and
low
con
trast
. use
soft
subfl
oors
(suc
h as
woo
den
subfl
oor)
inst
ead
of h
ard
subfl
oors
(suc
h as
conc
rete
sub
floor
).
Wan
der
gard
ens
x-
Wan
der
gard
en. a
fter
the
ope
ning
of a
wan
der
gard
en in
a d
emen
tia u
nit, s
igni
fican
t re
duct
ion
was
obs
erve
d in
res
iden
t fa
ll fr
eque
ncy
and
fall
seve
rity
scor
es (
det
wei
ler
et a
l., 2
00
9).
- det
wei
ler,
M. B
., M
urph
y, P
. F.,
Kim
, K. Y
., M
yers
, l.,
& a
shai
,
a. (2
009)
. sch
edul
ed m
edic
atio
ns a
nd fa
lls in
dem
entia
pat
ient
s
utili
zing
a w
ande
r gar
den.
am
eric
an J
ourn
al o
f alz
heim
er’s
dis
ease
& o
ther
dem
entia
s, 2
4(4)
, 322
–332
.
2Pr
ovid
e w
ande
r gar
den
for
dem
entia
pat
ient
s.
Skilled Nursing
Assisted Living
Dementia/ Alzheimer’s Care
Strength of Evidence
res
iden
T sa
FeTY
ris
K a
sses
sMen
T M
aTr
iX
abstract v
resident Safety risk assessment
11results |
Res
iden
t S
afet
y O
utco
mes
Des
ign
Feat
ures
Key
Fin
ding
sR
efer
ence
sD
esig
n R
ecom
men
datio
ns
Res
iden
t El
opem
ent/
U
nsaf
e E
xitin
g
ambi
ence
xx
- Pos
itive
dis
trac
tions
. Pos
itive
dis
tract
ions
in c
orrid
ors
incl
uded
nat
ure
scen
e w
all m
ural
s an
d po
ster
s of
fore
sts,
val
leys
, and
oth
ers;
art
ifici
al p
lant
s an
d tre
es;
natu
re s
ound
s; s
mel
l of f
ores
ts; h
ome/
peop
le s
cene
(b/w
pho
tos
of fa
mily
sce
nes)
; wal
l pos
ters
of f
amili
ar
pers
ons;
mus
ic, c
itrus
aro
ma;
arm
chai
r, co
ffee
tabl
e,
and
benc
hes.
nur
sing
hom
e re
side
nts
exhi
bite
d
few
er e
xit-s
eeki
ng a
nd tr
espa
ssin
g be
havi
ors
whe
n
posi
tive
dist
ract
ions
wer
e ad
ded
to th
e co
rrid
ors
(non
sign
ifica
nt) (
coh
en-M
ansfi
eld
& W
erne
r, 19
98a)
.
- Soo
thin
g en
viro
nmen
t. h
ighe
r ra
tings
of s
ooth
ing
ambi
ence
was
ass
ocia
ted
with
low
er le
vel o
f
wan
derin
g. B
right
er li
ghtin
g, g
reat
er v
aria
tion
in
soun
d le
vels
, pr
oxim
ity o
f oth
ers,
and
an
enga
ging
atm
osph
ere
wer
e as
soci
ated
with
hig
her
leve
l of
wan
derin
g (a
lgas
e et
al.,
201
0).
- alg
ase,
d.,
Bea
ttie,
e.,
anto
nako
s, c
., B
eel-B
ates
, c.,
& Y
ao,
l. (2
010)
. Wan
derin
g an
d th
e ph
ysic
al e
nviro
nmen
t. am
eric
an
Jour
nal o
f alz
heim
er’s
dis
ease
& o
ther
dem
entia
s, 2
5(4)
,
340
–346
.
- coh
en-M
ansfi
eld,
J.,
& W
erne
r, P.
(199
8a).
The
effe
cts
of a
n
enha
nced
env
ironm
ent o
n nu
rsin
g ho
me
resi
dent
s w
ho p
ace.
The
ger
onto
logi
st, 3
8(2)
, 199
–208
.
1Pr
ovid
e so
othi
ng, c
alm
ing,
posi
tive
dist
ract
ions
suc
h
as n
atur
e pi
ctur
es, n
atur
e
soun
ds, s
mel
ls o
f for
ests
,
hom
e sc
enes
, and
mus
ic
insi
de th
e fa
cilit
y.
des
ign
of e
xit
door
s
xx
- Vis
ual b
arrie
rs. c
amou
flage
of e
xit
door
s us
ing
mas
king
tap
es o
r cl
oth
pane
ls t
o co
ncea
l
door
knob
s m
ight
det
er u
nsaf
e ex
iting
of d
emen
tia
wan
dere
rs (
dic
kins
on &
Mcl
ain-
Kar
k, 1
99
6). B
oth
min
iblin
ds o
n th
e ex
it do
or t
hat
bloc
ked
the
view
to
outs
ide
and
clot
h pa
nels
tha
t co
ncea
led
door
knob
s
effe
ctiv
ely
redu
ced
exiti
ng d
ue t
o w
ande
ring
(dic
kins
on e
t al
., 19
95). a
wal
l mur
al d
esig
ned
to fi
t in
to t
he e
xist
ing
colo
rs a
nd d
esig
ns a
nd
pain
ted
over
exi
t do
ors
sign
ifica
ntly
red
uced
the
door
-tes
ting
beha
vior
s of
res
iden
ts w
ith d
emen
tia
(Kin
caid
& P
eaco
ck, 20
03)
. a
full-
leng
th m
irror
plac
ed in
fron
t of
exi
t do
or s
igni
fican
tly r
educ
ed
resi
dent
s’ e
xitin
g at
tem
pts
(May
er &
dar
by, 19
91).
- dic
kins
on, J
. i.,
& M
clai
n-K
ark,
J. (
1996
). W
ande
ring
beha
vior
asso
ciat
ed w
ith a
lzhe
imer
’s di
seas
e an
d re
late
d de
men
tias:
impl
icat
ions
for d
esig
ners
. Jou
rnal
of i
nter
ior d
esig
n, 2
2(1)
,
32–3
8.
- dic
kins
on, J
. i.,
Mcl
ain-
Kar
k, J
., &
Mar
shal
l-Bak
er, a
. (19
95).
The
effe
cts
of v
isua
l bar
riers
on
exiti
ng b
ehav
ior i
n a
dem
entia
care
uni
t. Th
e g
eron
tolo
gist
, 35(
1), 1
27.
- Kin
caid
, c.,
& P
eaco
ck, J
. r. (
2003
). Th
e ef
fect
of a
wal
l mur
al
on d
ecre
asin
g fo
ur ty
pes
of d
oor-t
estin
g be
havi
ors.
Jou
rnal
of
appl
ied
ger
onto
logy
, 22(
1), 7
6–8
8.
- May
er, r
., &
dar
by, s
. J. (
1991
). d
oes
a m
irror
det
er w
ande
ring
in d
emen
ted
olde
r peo
ple?
inte
rnat
iona
l Jou
rnal
of g
eria
tric
Psyc
hiat
ry, 6
(8),
607–
609.
2u
se v
isua
l bar
riers
suc
h
as m
aski
ng ta
pes,
clo
th
pane
ls, a
nd/o
r wal
l mur
al
desi
gn to
cam
oufla
ge th
e
exit
door
s an
d do
orkn
obs.
Blo
ck th
e vi
ews
to o
utsi
de
arou
nd e
xit d
oors
.
acce
ss to
saf
e
outd
oor a
reas
xx
- Acc
ess
to o
utdo
ors.
The
use
of e
xter
ior
envi
ronm
ents
red
uced
agg
ress
ive
beha
vior
s of
dem
ente
d re
side
nts
(Moo
ney
& n
icel
l, 19
92)
. a
fter
open
ing
a w
ande
r ga
rden
at
a de
men
tia fa
cilit
y,
resi
dent
s’ a
gita
tion
leve
l (m
easu
red
by a
sta
ndar
d
ratin
g sc
ale)
and
the
use
of a
s-ne
eded
med
icat
ions
decr
ease
d (d
etw
eile
r et
al.,
20
08)
.
- det
wei
ler,
M. B
., M
urph
y, P
. F.,
Mye
rs, l
., &
Kim
, K. Y
. (20
08).
doe
s a
wan
der g
arde
n in
fluen
ce in
appr
opria
te b
ehav
iors
in
dem
entia
resi
dent
s? a
mer
ican
Jou
rnal
of a
lzhe
imer
’s d
isea
se &
oth
er d
emen
tias,
23(
1), 3
1–45
.
- Moo
ney,
P.,
& n
icel
l, P.
(199
2). T
he im
port
ance
of e
xter
ior
envi
ronm
ents
for a
lzhe
imer
’s re
side
nts:
effe
ctiv
e ca
re a
nd ri
sk
man
agem
ent.
hea
lthca
re M
anag
emen
t For
um, 5
(2),
23–2
9.
2if
poss
ible
, pro
vide
saf
e
outd
oor a
reas
that
can
be
acce
ssed
from
exi
t doo
rs.
Prov
ide
safe
tran
sitio
ns
betw
een
indo
or a
nd
outd
oor a
reas
.
Skilled Nursing
Assisted Living
Dementia/ Alzheimer’s Care
Strength of Evidence
res
iden
T sa
FeTY
ris
K a
sses
sMen
T M
aTr
iX
abstract v
resident Safety risk assessment
12results |
Res
iden
t S
afet
y O
utco
mes
Des
ign
Feat
ures
Key
Fin
ding
sR
efer
ence
sD
esig
n R
ecom
men
datio
ns
Slee
p D
isor
ders
sunl
ight
expo
sure
xx
- Sun
light
. Th
irty
min
utes
or
mor
e of
dai
ly s
unlig
ht
expo
sure
(to
geth
er w
ith o
ther
inte
rven
tions
, e.
g.,
incr
ease
d ph
ysic
al a
ctiv
ity, ef
fort
s to
dec
reas
e
nigh
ttim
e no
ise
and
light
ing)
res
ulte
d in
dec
reas
e
in t
he d
urat
ion
of n
ight
time
awak
enin
gs a
nd
decr
ease
in d
aytim
e sl
eep
(ale
ssi e
t al
., 20
05)
.
- ale
ssi,
c. a
., M
artin
, J. l
., W
ebbe
r, a.
P.,
Kim
, e. c
., h
arke
r, J.
o.,
& J
osep
hson
, K. r
. (20
05).
ran
dom
ized
, con
trolle
d tri
al o
f a
nonp
harm
acol
ogic
al in
terv
entio
n to
impr
ove
abno
rmal
sle
ep/w
ake
patte
rns
in n
ursi
ng h
ome
resi
dent
s. J
ourn
al o
f the
am
eric
an
ger
iatri
cs s
ocie
ty, 5
3(5)
, 803
–810
.
- slo
ane,
P. d
., n
oell-
Wag
gone
r, e.
, hic
kman
, s.,
Mitc
hell,
c. M
.,
Will
iam
s, c
. s.,
Prei
sser
, J. s
., et
al.
(200
5). i
mpl
emen
ting
a
light
ing
inte
rven
tion
in p
ublic
are
as o
f lon
g-te
rm c
are
faci
litie
s:
less
ons
lear
ned.
alz
heim
er’s
care
Qua
rter
ly, 6
(4),
280
–293
.
1Pr
ovid
e am
ple
sunl
ight
expo
sure
in a
nd a
roun
d
the
build
ing.
expo
sure
to
artifi
cial
brig
ht
light
xx
- B
right
ligh
t. T
wo-
hour
exp
osur
e of
1,5
00
–2,0
00
lux
brig
ht li
ght
betw
een
7 a
nd 9
p.m
. de
ceas
ed
slee
p-w
akef
ulne
ss o
f dem
entia
pat
ient
s as
rat
ed
by s
taff
(sat
lin e
t al
., 19
92)
. Tw
o-ho
ur b
right
ligh
t
(6,0
00
–8,0
00
lux)
bet
wee
n 8
and
11
a.m
. le
d to
impr
oved
sle
ep a
t ni
ght;
sle
ep e
ffici
ency
(%
sle
ep
of t
otal
bed
time)
incr
ease
d fr
om 7
3% t
o 8
6%,
and
tota
l noc
turn
al w
ake
decr
ease
d by
2 h
ours
as
mea
sure
d by
act
iwat
ch w
orn
on w
rist
(Fet
veit
&
Bjo
rvat
n, 2
00
4).
- Fet
veit,
a.,
& B
jorv
atn,
B. (
2004
). Th
e ef
fect
s of
brig
ht-li
ght
ther
apy
on a
ctig
raph
ical
mea
sure
d sl
eep
last
for s
ever
al w
eeks
post
-trea
tmen
t. a
stud
y in
a n
ursi
ng h
ome
popu
latio
n. J
ourn
al o
f
slee
p r
esea
rch,
13(
2), 1
53–1
58.
- sat
lin, a
., Vo
licer
, l.,
ros
s, V
., h
erz,
l.,
& c
ampb
ell,
s. (1
992)
.
Brig
ht li
ght t
reat
men
t of b
ehav
iora
l and
sle
ep d
istu
rban
ces.
The
amer
ican
Jou
rnal
of P
sych
iatr
y, 1
49(8
), 10
28.
2Pr
ovid
e ar
tifici
al b
right
light
exp
osur
e (>
1,50
0
lux)
.
illum
inat
ion
leve
l
xx
- Env
iron
men
tal l
ight
ing
leve
l. Th
e in
crea
se o
f
light
ing
leve
ls (
from
ave
rage
436
lux
to 1
,136
lux)
in p
atie
nt li
ving
roo
ms
resu
lted
in m
ore
stab
le r
est-
activ
ity r
hyth
ms
amon
g de
men
ted
patie
nts
as m
easu
red
by a
ctiw
atch
(Va
n so
mer
en
et a
l., 1
997
). h
ighe
r lig
htin
g le
vels
dur
ing
dayt
ime
(7 a
.m. to
7 p
.m.)
was
ass
ocia
ted
with
few
er a
wak
enin
gs in
nur
sing
hom
e re
side
nts
at
nigh
t (s
hoch
at e
t al
., 20
00)
. g
reat
er 2
4-h
our
illum
inat
ion
amou
nt w
as a
ssoc
iate
d w
ith s
hort
er
slee
p la
tenc
ies
(from
ligh
ts o
ut t
o th
e fir
st s
leep
)
and
redu
ced
wak
e w
ithin
sle
ep (
hom
e re
side
nts,
Wal
lace
-guy
et
al.,
200
2).
- sho
chat
, T.,
Mar
tin, J
., M
arle
r, M
., &
anc
oli-i
srae
l, s.
(200
0).
illum
inat
ion
leve
ls in
nur
sing
hom
e pa
tient
s: e
ffect
s on
sle
ep a
nd
activ
ity rh
ythm
s. J
ourn
al o
f sle
ep r
esea
rch,
9(4
), 37
3–3
79.
- Van
som
eren
, e. J
. W.,
Kess
ler,
a., M
irmira
n, M
., &
sw
aab,
d.
F. (1
997)
. ind
irect
brig
ht li
ght i
mpr
oves
circ
adia
n re
st-a
ctiv
ity
rhyt
hm d
istu
rban
ces
in d
emen
ted
patie
nts.
Bio
logi
cal P
sych
iatr
y,
41(9
), 95
5–9
63.
- Wal
lace
-guy
, g.,
Krip
ke, d
., Je
an-l
ouis
, g.,
lang
er, r
., el
liott,
J.,
& T
uuna
inen
, a. (
2002
). ev
enin
g lig
ht e
xpos
ure:
impl
icat
ions
for
slee
p an
d de
pres
sion
. Jou
rnal
of t
he a
mer
ican
ger
iatri
cs s
ocie
ty,
50(4
), 73
8–7
39.
2d
esig
n th
e am
bien
t
light
ing
so th
at th
e
illum
inat
ion
leve
l is
high
.
Skilled Nursing
Assisted Living
Dementia/ Alzheimer’s Care
Strength of Evidence
res
iden
T sa
FeTY
ris
K a
sses
sMen
T M
aTr
iX
abstract v
resident Safety risk assessment
13results |
Res
iden
t S
afet
y O
utco
mes
Des
ign
Feat
ures
Key
Fin
ding
sR
efer
ence
sD
esig
n R
ecom
men
datio
ns
Slee
p D
isor
ders
red
uced
nigh
ttim
e
nois
e an
d
dist
urba
nce
x- L
ight
cha
nge.
red
uctio
n of
pea
k no
ise
leve
l and
light
cha
nges
at
nigh
ttim
e w
as a
ssoc
iate
d w
ith
redu
ced
num
ber
of a
wak
enin
gs a
nd im
prov
ed s
leep
effic
ienc
y %
of t
ime
spen
t in
sle
ep)
(sch
nelle
et
al.,
199
9). n
ight
time
slee
p of
nur
sing
hom
e re
side
nts
was
adv
erse
ly a
ffec
ted
by n
oise
and
ligh
t (s
chne
lle
et a
l., 1
99
8). e
xter
nal f
acto
rs c
ausi
ng s
leep
diffi
culti
es in
clud
ed n
oise
, lig
ht, an
d di
srup
tion
from
roo
mm
ates
(K
och
et a
l., 2
00
6).
- En
viro
nmen
tal n
oise
. en
viro
nmen
tal n
oise
(e.g
.,
phon
e rin
g) a
nd s
taff-
gene
rate
d no
ise
acco
unte
d
for
sign
ifica
nt p
ortio
n of
nig
httim
e no
ise;
hal
f of t
he
nois
es w
ere
loud
eno
ugh
to d
isru
pt s
leep
(W
ebbe
r
et a
l., 2
00
4). n
oise
was
the
mos
t co
mm
on fa
ctor
caus
ing
slee
p di
stur
banc
e as
rep
orte
d by
nur
sing
hom
e re
side
nts
and
the
elde
rly in
reh
abili
tatio
n
war
d (e
rsse
r et
al.,
19
99)
.
- ers
ser,
s., W
iles,
a.,
Tayl
or, h
., W
ade,
s.,
Wal
s, r
., &
Ben
tley,
T.
(199
9). T
he s
leep
of o
lder
peo
ple
in h
ospi
tal a
nd n
ursi
ng h
omes
.
Jour
nal o
f clin
ical
nur
sing
, 8(4
), 36
0–3
68.
- Koc
h, s
., h
aesl
er, e
., Ti
zian
i, a.
, & W
ilson
, J. (
2006
).
effe
ctiv
enes
s of
sle
ep m
anag
emen
t stra
tegi
es fo
r res
iden
ts o
f
aged
car
e fa
cilit
ies:
Fin
ding
s of
a s
yste
mat
ic re
view
. Jou
rnal
of
clin
ical
nur
sing
, 15(
10),
1267
–127
5.
- ous
land
er, J
. g.,
con
nell,
B. r
., B
liwis
e, d
. l.,
ende
shaw
, Y.,
grif
fiths
, P.,
& s
chne
lle, J
. F. (
2006
). a
nonp
harm
acol
ogic
al
inte
rven
tion
to im
prov
e sl
eep
in n
ursi
ng h
ome
patie
nts:
res
ults
of a
con
trolle
d cl
inic
al tr
ial.
Jour
nal o
f The
am
eric
an g
eria
trics
soci
ety,
54(
1), 3
8–4
7.
- sch
nelle
, J. F
., al
essi
, c. a
., al
-sam
arra
i, n
. r.,
Fric
ker,
r. d
., Jr
.,
& o
usla
nder
, J. g
. (19
99).
The
nurs
ing
hom
e at
nig
ht: e
ffect
s of
an in
terv
entio
n on
noi
se, l
ight
, and
sle
ep. J
ourn
al o
f am
eric
an
ger
iatri
cs s
ocie
ty, 4
7(4)
, 430
–438
.
- sch
nelle
, J. F
., cr
uise
, P.
a., a
less
i, c.
a.,
ludl
ow, K
., al
-
sam
arra
i, n
. r.,
& o
usla
nder
, J. g
. (19
98).
slee
p hy
gien
e in
phys
ical
ly d
epen
dent
nur
sing
hom
e re
side
nts:
Beh
avio
ral a
nd
envi
ronm
enta
l int
erve
ntio
n im
plic
atio
ns. s
leep
, 21(
5), 5
15–5
23.
- Web
ber,
a., M
artin
, J.,
ales
si, c
., Jo
seph
son,
K.,
& h
arke
r, J.
(200
4). n
ight
time
nois
e in
the
post
-acu
te re
habi
litat
ion
nurs
ing
hom
e se
tting
. The
ger
onto
logi
st, 4
4(1)
, 38.
2r
educ
e or
elim
inat
e
envi
ronm
enta
l fac
tors
caus
ing
slee
p di
stur
banc
e
such
as
nois
e, li
ght
chan
ges,
and
dis
rupt
ion
from
room
mat
es.
roo
m
occu
panc
y
x- S
ingl
e ro
om. M
ovin
g fr
om m
ultib
ed r
oom
s to
sing
le r
oom
s re
sulte
d in
bet
ter
slee
p an
d fe
wer
inte
rven
tions
(e.g
., m
edic
atio
ns)
to p
rom
ote
slee
p
at n
ight
in d
emen
ted
resi
dent
s (M
orga
n &
ste
war
t,
199
8a)
. d
isru
ptio
n fr
om r
oom
mat
es w
as o
ne o
f
the
exte
rnal
fact
ors
caus
ing
slee
p di
fficu
lties
(K
och
et a
l., 2
00
6).
- Koc
h, s
., h
aesl
er, e
., Ti
zian
i, a.
, & W
ilson
, J. (
2006
).
effe
ctiv
enes
s of
sle
ep m
anag
emen
t stra
tegi
es fo
r res
iden
ts o
f
aged
car
e fa
cilit
ies:
Fin
ding
s of
a s
yste
mat
ic re
view
. Jou
rnal
of
clin
ical
nur
sing
, 15(
10),
1267
–127
5.
- Mor
gan,
d. g
., &
ste
war
t, n
. J. (
1998
a). M
ultip
le o
ccup
ancy
vers
us p
rivat
e ro
oms
on d
emen
tia c
are
units
. env
ironm
ent &
Beh
avio
r, 30
(4),
487–
503.
1-2
Prov
ide
sing
le ro
oms.
illum
inat
ion
leve
l
xx
- Acc
ess
to o
utdo
ors.
acc
ess
to o
utdo
ors
prov
ided
expo
sure
to
brig
ht li
ght
and
natu
ral e
lem
ents
and
help
ed im
prov
e th
e sl
eep
of n
ursi
ng h
ome
resi
dent
s w
ith d
emen
tia (c
alki
ns e
t al
., 20
07).
- cal
kins
, M.,
szm
erek
ovsk
y, J
. g.,
& B
iddl
e, s
. (20
07).
effe
ct
of in
crea
sed
time
spen
t out
door
s on
indi
vidu
als
with
dem
entia
resi
ding
in n
ursi
ng h
omes
. Jou
rnal
of h
ousi
ng fo
r the
eld
erly,
21(3
/4),
211–
228.
1-2
Prov
ide
acce
ss to
outd
oors
for n
ursi
ng h
ome
resi
dent
s w
ith d
emen
tia.
Skilled Nursing
Assisted Living
Dementia/ Alzheimer’s Care
Strength of Evidence
res
iden
T sa
FeTY
ris
K a
sses
sMen
T M
aTr
iX
abstract v
resident Safety risk assessment
14results |
Res
iden
t S
afet
y O
utco
mes
Des
ign
Feat
ures
Key
Fin
ding
sR
efer
ence
sD
esig
n R
ecom
men
datio
ns
Agg
ress
ion
and
Dis
rupt
ive
Beh
avio
r
uni
t siz
ex
x- U
nit
size
. la
rge
unit
size
was
ass
ocia
ted
with
hig
her
leve
l of
agita
tion
in d
emen
ted
resi
dent
s (s
loan
e et
al.,
19
98)
. la
rge
unit
size
was
cor
rela
ted
with
hig
h le
vel o
f tim
e pr
essu
re a
mon
g st
aff
and
low
leve
ls o
f qua
lity
of li
fe in
res
iden
ts a
t lo
ng-t
erm
car
e
faci
litie
s (P
ekka
rinen
et
al.,
200
4). d
emen
ted
resi
dent
s ha
d
impr
ovem
ents
in d
isru
ptiv
e be
havi
ors
whe
n th
ey m
oved
from
a
69-b
ed u
nit
to t
wo
20-b
ed s
ubun
its w
ith m
ore
spac
e fo
r ea
ch
patie
nt (3
8 v
s. 1
7 m
2/re
side
nt)
(Mor
gan
& s
tew
art, 1
99
8b)
.
- Mor
gan,
d.g
., &
stew
art,
n. J
. (19
98b)
. hig
h ve
rsus
low
den
sity
spec
ial c
are
units
: im
pact
on
the
beha
vior
of e
lder
ly re
siden
ts w
ith d
emen
tia. c
anad
ian
Jour
nal o
n
agin
g, 1
7(2)
, 143
–165
.
- Pek
karin
en, l
., si
nver
vo, T
., Pe
rala,
M.-l
., &
elov
ainio,
M.
(200
4). W
ork
stre
ssor
s and
the
quali
ty o
f life
in lo
ng-te
rm
care
uni
ts. T
he g
eron
tolo
gist,
44(5
), 63
3–64
3.
- slo
ane,
P. d
., M
itche
ll, c
. M.,
Prei
sser
, J.,
Philli
ps, c
.,
com
man
der,
c., &
Bur
ke, e
. (19
98).
envir
onm
enta
l
corre
late
s of
resid
ent a
gita
tion
in a
lzhei
mer
’s di
seas
e
spec
ial c
are
units
. Jou
rnal
of t
he a
mer
ican
ger
iatri
cs
soci
ety,
46(
7), 8
62–8
69.
1-2
red
uce
unit
size
(< 2
0
resi
dent
s pe
r uni
t).
ambi
ance
xx
x- P
ositi
ve d
istr
actio
ns in
cor
ridor
s (n
atur
e sc
ene,
hom
e/pe
ople
sc
ene,
incl
udin
g vi
sual
, aud
io, a
nd o
lfact
ory
stim
uli).
nur
sing
ho
me
resi
dent
s ex
hibi
ted
few
er a
gita
ted
and
aggr
essi
ve
beha
vior
s w
hen
posi
tive
dist
ract
ions
wer
e ad
ded
to th
e co
rrid
ors
(non
sign
ifica
nt)
(coh
en-M
ansfi
eld
& W
erne
r, 19
98a)
.
- Aes
thet
ics
and
amen
ities
. hom
elik
e en
viro
nmen
t, cl
eanl
ines
s an
d m
aint
enan
ce o
f env
ironm
ent,
nong
lare
and
non
slip
floo
rs, p
ublic
ki
tche
n fo
r act
iviti
es w
ere
fact
ors
asso
ciat
ed w
ith lo
wer
leve
ls o
f ag
itatio
n in
dem
ente
d re
side
nts
(slo
ane
et a
l., 1
998)
. afte
r the
re
nova
tions
of c
hron
ic m
enta
l uni
ts (e
.g.,
low
ered
cei
ling,
sha
ded
light
s, li
ght-c
olor
ed ti
les,
vin
yl w
alls
with
cal
m c
olor
s an
d sy
lvan
de
sign
s in
day
room
; fur
nitu
re re
grou
ped
for d
iffer
ent a
ctiv
ities
; ful
l ca
rpet
ing;
non
inst
itutio
nal c
lock
s; o
rnam
enta
l cer
amic
tile
s, fu
ll-le
ngth
m
irror
s, v
anity
-sty
le s
inks
, and
woo
d-co
vere
d ca
bine
ts in
bat
hroo
ms
with
priv
ate
dres
sing
room
s), p
atie
nt v
iole
nce
sign
ifica
ntly
dec
reas
ed
(alm
ost 5
0%),
and
patie
nt s
atis
fact
ion
incr
ease
d (c
hris
tenf
eld,
W
agne
r, Pa
stva
, & a
cris
h, 1
989)
. Fac
ility
mai
nten
ance
, han
drai
ls,
call
butto
ns, r
oom
aut
onom
y (in
depe
nden
t con
trol o
f hea
ting,
ac,
an
d do
or),
tele
phon
e, p
rivac
y (p
rivat
e pa
tient
room
, toi
let,
bath
room
) w
ere
envi
ronm
enta
l ele
men
ts re
late
d to
low
er fr
eque
ncy/
seve
rity
of
neur
opsy
chia
tric
sym
ptom
s (B
icke
t et a
l., 2
010)
.
- Hou
se-li
ke s
mal
l uni
t. Pa
tient
s in
pur
pose
-bui
lt bu
ngal
ows
(eac
h of
w
hich
was
occ
upie
d by
four
pat
ient
s an
d de
sign
ed to
refle
ct a
“ho
use”
[s
ingl
e be
droo
m, k
itche
n, lo
unge
, gar
den]
) exp
erie
nced
sig
nific
antly
lo
wer
leve
ls o
f psy
chia
tric
diffi
culty
than
pat
ient
s in
trad
ition
al lo
ng-
term
psy
chia
tric
units
(Mcg
onag
le &
alla
n, 2
002)
. gre
en h
ouse
(sm
all
scal
e, p
rivat
e ro
oms
and
bath
room
s, re
side
ntia
l kitc
hen,
din
ing,
and
he
arth
; cer
tified
nur
sing
ass
ista
nts;
vis
iting
clin
ical
sup
port
team
) was
as
soci
ated
with
low
er le
vel o
f dep
ress
ion
(Kan
e et
al.,
200
7).
- Bic
ket,
M.c
., sa
mus
, Q.M
., M
cnab
ney,
M.,
ony
ike,
c.
u.,
May
er, l
.s.,
Bra
ndt,
J., e
t al.
(201
0). T
he
phys
ical
env
ironm
ent i
nflue
nces
neu
rops
ychi
atric
sy
mpt
oms
and
othe
r out
com
es in
ass
iste
d liv
ing
resi
dent
s. in
tern
atio
nal J
ourn
al o
f ger
iatri
c Ps
ychi
atry
, 25
(10)
, 104
4–1
054.
- chr
iste
nfel
d, r
., W
agne
r, J.
, Pas
tva,
g.,
& a
cris
h,
W. P
. (19
89).
how
phy
sica
l set
tings
affe
ct c
hron
ic
men
tal p
atie
nts.
Psy
chia
tric
Qua
rter
ly, 6
0(3)
, 25
3–2
64.
- coh
en-M
ansfi
eld,
J.,
& W
erne
r, P.
(199
8a).
The
effe
cts
of a
n en
hanc
ed e
nviro
nmen
t on
nurs
ing
hom
e re
side
nts
who
pac
e. T
he g
eron
tolo
gist
, 38(
2),
199
–208
.- K
ane,
r. a
., lu
m, T
. Y.,
cutle
r, l.
J.,
deg
enho
ltz, h
. B
., &
Yu,
T.-c
. (20
07).
res
iden
t out
com
es in
sm
all-
hous
e nu
rsin
g ho
mes
: a lo
ngitu
dina
l eva
luat
ion
of
the
initi
al g
reen
hou
se p
rogr
am. J
ourn
al o
f am
eric
an
ger
iatri
cs s
ocie
ty, 5
5(6)
, 832
–839
.- M
cgon
agle
, i. M
., &
alla
n, s
. (20
02).
a co
mpa
rison
of
beh
avio
ur in
two
diffe
ring
psyc
hiat
ric lo
ng-s
tay
reha
bilit
atio
n en
viro
nmen
ts. J
ourn
al o
f Psy
chia
tric
&
Men
tal h
ealth
nur
sing
, 9(4
), 49
3–4
99.
- slo
ane,
P. d
., M
itche
ll, c
. M.,
Prei
sser
, J.,
Phill
ips,
c.,
com
man
der,
c., &
Bur
ke, e
. (19
98).
envi
ronm
enta
l co
rrel
ates
of r
esid
ent a
gita
tion
in a
lzhe
imer
’s di
seas
e sp
ecia
l car
e un
its. J
ourn
al o
f the
am
eric
an g
eria
trics
so
ciet
y, 4
6(7)
, 862
–869
.
2Pr
ovid
e po
sitiv
e di
stra
ctio
ns s
uch
as
natu
re s
cene
s, s
ound
s,
and
smel
ls, h
ome
scen
es, a
nd m
usic
in
the
corr
idor
s. i
nteg
rate
ho
mel
ike
elem
ents
in
the
envi
ronm
ent d
esig
n su
ch a
s pr
ivat
e ro
oms,
pr
ivat
e ba
thro
oms,
sh
aded
ligh
ts, l
ower
ed
ceili
ng, f
ull c
arpe
t, an
d no
nins
titut
iona
l fu
rnitu
re.
Skilled Nursing
Assisted Living
Dementia/ Alzheimer’s Care
Strength of Evidence
res
iden
T sa
FeTY
ris
K a
sses
sMen
T M
aTr
iX
abstract v
resident Safety risk assessment
15results |
Res
iden
t S
afet
y O
utco
mes
Des
ign
Feat
ures
Key
Fin
ding
sR
efer
ence
sD
esig
n R
ecom
men
datio
ns
Agg
ress
ion
and
Dis
rupt
ive
Beh
avio
r
roo
m
occu
panc
y
xx
- Sin
gle
room
. Mov
ing
from
a u
nit w
ith m
ultib
ed
room
s to
ano
ther
uni
t with
all
sing
le r
oom
s re
sulte
d
in im
prov
emen
ts in
dem
ente
d re
side
nts’
beh
avio
rs
(incr
ease
d no
ndis
rupt
ive
beha
vior
and
dec
reas
ed
disr
uptiv
e be
havi
or)
(Mor
gan
& s
tew
art,
1998
b).
Bei
ng in
a s
hare
d ro
om w
as a
sig
nific
ant p
redi
ctor
of
“unc
oope
rativ
enes
s” o
f nur
sing
hom
e re
side
nts
(e.g
.,
refu
sing
to fo
llow
sta
ff re
ques
t, ve
rbal
abu
se)
(low
et a
l., 2
00
4).
- low
, l.-F
., d
rape
r, B
., &
Bro
daty
, h. (
2004
). Th
e re
latio
nshi
p
betw
een
self-
dest
ruct
ive
beha
viou
r and
nur
sing
hom
e
envi
ronm
ent.
agi
ng &
Men
tal h
ealth
, 8(1
), 29
–33.
- Mor
gan,
d. g
., &
ste
war
t, n
. J. (
1998
b). h
igh
vers
us lo
w d
ensi
ty
spec
ial c
are
units
: im
pact
on
the
beha
viou
r of e
lder
ly re
side
nts
with
dem
entia
. can
adia
n Jo
urna
l on
agi
ng, 1
7(2)
, 143
–165
.
1-2
Prov
ide
sing
le ro
oms.
Mus
ic/n
atur
e
soun
ds/n
oise
xx
- Nat
ure
soun
ds. W
hen
the
audi
otap
es o
f tw
o ty
pes
of n
atur
e so
unds
(mou
ntai
n st
ream
and
gen
tle
ocea
n) w
ere
play
ed, n
ursi
ng h
ome
resi
dent
s
exhi
bite
d lo
wer
leve
l of v
erba
l agi
tatio
n th
an w
hen
the
audi
otap
es w
ere
turn
ed o
ff (B
urgi
o et
al.,
199
6).
- N
oise
. lou
d no
ises
(e.g
., lo
ud t
alki
ng, s
ingi
ng, a
nd
clap
ping
) w
ere
rela
ted
to a
gita
tion
and
disr
uptiv
e
beha
vior
s (n
elso
n, 1
995)
.
- Bur
gio,
l.,
scill
ey, K
., h
ardi
n, M
., h
su, c
., &
Yan
cey,
J. (
1996
).
envi
ronm
enta
l “w
hite
noi
se”:
an in
terv
entio
n fo
r ver
bally
agi
tate
d
nurs
ing
hom
e re
side
nts.
The
Jou
rnal
s of
ger
onto
logy
, 51B
(6),
P364
–P37
3.
- nel
son,
J. (
1995
). Th
e in
fluen
ce o
f env
ironm
enta
l fac
tors
in in
cide
nts
of d
isru
ptiv
e be
havi
or. J
ourn
al o
f ger
onto
logi
cal
nur
sing
, 21(
5), 1
9–2
4.
2Pr
ovid
e ac
cess
to n
atur
e
soun
ds. r
educ
e lo
ud
nois
es.
ligh
t lev
els/
brig
ht li
ght
x- E
nviro
nmen
tal l
ight
ing
leve
l. lo
w in
tens
ity o
f
envi
ronm
enta
l lig
htin
g w
as a
ssoc
iate
d w
ith in
crea
sed
agita
tion
in d
emen
ted
resi
dent
s (s
loan
e et
al.,
199
8).
dem
ente
d re
side
nts
exhi
bite
d le
ss a
gita
tion
whe
n
dini
ng e
nviro
nmen
t inc
orpo
rate
d br
ight
er li
ght a
nd
heig
hten
ed c
olor
con
trast
(Kos
s &
gilm
ore,
199
8).
- Brig
ht li
ght.
Brig
ht li
ght e
xpos
ure
in m
orni
ng (3
hr, 2
,500
lux)
resu
lted
in s
igni
fican
t red
uctio
n of
agita
tion
beha
vior
s of
resi
dent
s (m
anua
l man
ipul
atio
n,
esca
pe re
stra
ints
, sea
rchi
ng a
nd w
ande
ring,
tapp
ing
and
bang
ing,
voc
aliz
atio
n) (l
ovel
l et a
l., 1
995)
.
- Blo
ckin
g af
tern
oon
sunl
ight
. a li
ghtin
g in
terv
entio
n—
bloc
king
dire
ct a
ftern
oon
sunl
ight
by
the
mic
rosl
atte
d
glaz
ed w
indo
ws
and
mai
ntai
ning
a c
onst
ant l
ight
leve
l dur
ing
afte
rnoo
n by
a li
ghtin
g sy
stem
incl
udin
g
a ph
oto
sens
or a
nd lu
min
arie
s w
ith fu
ll-sp
ectr
um
lam
ps—
sign
ifica
ntly
redu
ced
disr
uptiv
e be
havi
ors
in
indi
vidu
als
with
alz
heim
er’s
dis
ease
at s
enio
r adu
lt
day-
care
cen
ter (
la g
arce
, 20
02; l
a g
arce
, 20
04).
- Kos
s, e
., &
gilm
ore,
g. c
. (1
998)
. env
ironm
enta
l int
erve
ntio
ns
and
func
tiona
l abi
lity
of a
d p
atie
nts.
in B
. Vel
las,
J. F
itten
, & g
.
Fris
oni (
eds.
), r
esea
rch
and
prac
tice
in a
lzhe
imer
’s di
seas
e 19
98
(pp.
185
–193
). n
ew Y
ork:
spr
inge
r.
- la
gar
ce, M
. (20
02).
ligh
ting
affe
cts
beha
vior
of a
lzhe
imer
’s
patie
nts.
Jou
rnal
of i
nter
ior d
esig
n, 2
8(2)
, 15
–25.
- la
gar
ce, M
. (20
04).
day
light
inte
rven
tions
and
alz
heim
er’s
beha
vior
s—a
twel
ve-m
onth
stu
dy. J
ourn
al o
f arc
hite
ctur
al a
nd
Plan
ning
res
earc
h, 2
3(3)
, 257
–269
.
- lov
ell,
B. B
., an
coli-
isra
el, s
., &
gev
irtz,
r. (
1995
). ef
fect
of
brig
ht li
ght t
reat
men
t on
agita
ted
beha
vior
in in
stitu
tiona
lized
elde
rly s
ubje
cts.
Psy
chia
try
res
earc
h, 5
7(1)
, 7–1
2.
- slo
ane,
P. d
., M
itche
ll, c
. M.,
Prei
sser
, J.,
Phill
ips,
c.,
com
man
der,
c., &
Bur
ke, e
. (19
98).
envi
ronm
enta
l cor
rela
tes
of re
side
nt a
gita
tion
in a
lzhe
imer
’s di
seas
e sp
ecia
l car
e un
its.
Jour
nal o
f the
am
eric
an g
eria
trics
soc
iety
, 46(
7), 8
62–8
69.
2in
crea
se th
e ill
umin
atio
n
leve
l of a
mbi
ent l
ight
ing.
Blo
ck a
ftern
oon
sunl
ight
from
ent
erin
g pa
tient
room
s, k
eep
light
ing
leve
l con
tsta
nt d
urin
g
afte
rnoo
n.
Skilled Nursing
Assisted Living
Dementia/ Alzheimer’s Care
Strength of Evidence
res
iden
T sa
FeTY
ris
K a
sses
sMen
T M
aTr
iX
abstract v
resident Safety risk assessment
16results |
Res
iden
t S
afet
y O
utco
mes
Des
ign
Feat
ures
Key
Fin
ding
sR
efer
ence
sD
esig
n R
ecom
men
datio
ns
Agg
ress
ion
and
Dis
rupt
ive
Beh
avio
r
acce
ss
to n
atur
e/
outd
oors
xx
- Ac
cess
to o
utdo
ors
(wan
der g
arde
n). T
he u
se
of e
xter
ior
envi
ronm
ents
red
uced
agg
ress
ive
beha
vior
s of
dem
ente
d re
side
nts
(Moo
ney
&
nic
ell,
199
2). Th
e nu
mbe
r of
gar
den
visi
ts w
as
sign
ifica
ntly
ass
ocia
ted
with
the
agi
tatio
n le
vel
of d
emen
tia p
atie
nts
(Mur
phy
et a
l., 2
010)
. a
fter
open
ing
a w
ande
r ga
rden
at
a de
men
tia fa
cilit
y,
resi
dent
s’ a
gita
tion
leve
l (m
easu
red
by a
sta
ndar
d
ratin
g sc
ale)
and
the
use
of a
s-ne
eded
med
icat
ions
decr
ease
d (d
etw
eile
r et
al.,
20
08)
. d
emen
tia
resi
dent
s ex
hibi
ted
few
er a
gita
ted
beha
vior
s (e
.g.,
agita
ted
paci
ng, ag
itate
d w
alki
ng, re
stle
ssne
ss)
whe
n th
e ex
it do
ors
to o
utdo
or t
erra
ce/g
arde
n ar
ea
wer
e un
lock
ed t
han
whe
n th
e do
ors
wer
e lo
cked
(nam
azi &
Joh
nson
, 19
92)
. Vi
sits
to
an o
utdo
or
gard
en h
elpe
d de
crea
se a
gita
tion
beha
vior
s (e
.g.,
tres
pass
ing,
exi
ting)
in n
ursi
ng h
ome
resi
dent
s
with
dem
entia
(c
ohen
-Man
sfiel
d &
Wer
ner,
199
8b)
. a
cces
s to
out
door
s re
sulte
d in
dec
reas
es
of v
erba
l and
phy
sica
l agg
ress
ion
in p
atie
nts
with
dem
entia
in a
n ac
ute
psyc
hoge
riatr
ic a
dmis
sion
unit
(McM
inn
& h
into
n, 2
00
0).
- Ac
cess
to n
atur
e el
emen
ts. T
he u
se o
f nat
ural
elem
ents
(rec
orde
d so
unds
of b
irds,
bab
blin
g
broo
ks, an
d ot
her
smal
l ani
mal
s; la
rge
brig
ht
pict
ures
coo
rdin
ated
with
the
aud
io t
apes
) to
geth
er
with
oth
er d
istr
actio
ns in
clud
ing
food
s (s
uch
as
bana
na p
uddi
ng a
nd s
oda)
dur
ing
show
ers/
bath
s
resu
lted
in s
igni
fican
t re
duct
ion
of d
emen
tia
patie
nts’
agi
tatio
n an
d ag
gres
sion
and
mor
e
posi
tive
affe
ctiv
e re
spon
ses
(Wha
ll et
al.,
19
97).
- c
ohen
-Man
sfiel
d, J
., &
Wer
ner,
P. (1
998b
). Vi
sits
to a
n
outd
oor
gard
en: i
mpa
ct o
n be
havi
or a
nd m
ood
of n
ursi
ng h
ome
resi
dent
s w
ho p
ace.
in B
. Vel
las,
J. F
itten
, & g
. Fris
oni (
eds.
),
res
earc
h an
d pr
actic
e in
alz
heim
er’s
dis
ease
(pp
. 419
-436
).
new
Yor
k: s
prin
ger.
- d
etw
eile
r, M
. B.,
Mur
phy,
P. F
., M
yers
, l.,
& K
im, K
. Y.
(20
08)
. doe
s a
wan
der
gard
en in
fluen
ce in
appr
opria
te
beha
vior
s in
dem
entia
res
iden
ts?
am
eric
an J
ourn
al o
f
alzh
eim
er’s
dis
ease
& o
ther
dem
entia
s, 2
3(1)
, 31–
45.
- M
cMin
n, B
. g.,
& h
into
n, l
. (20
00)
. con
fined
to b
arra
cks:
The
effe
cts
of in
door
con
finem
ent o
n ag
gres
sive
beh
avio
r am
ong
inpa
tient
s of
an
acut
e ps
ycho
geria
tric
uni
t. am
eric
an J
ourn
al o
f
alzh
eim
er’s
dis
ease
and
oth
er d
emen
tias,
15(
1), 3
6–4
1.
- M
oone
y, P
., &
nic
ell,
P. (1
992)
. The
impo
rtan
ce o
f ext
erio
r
envi
ronm
ents
for
alzh
eim
er’s
res
iden
ts: e
ffect
ive
care
and
ris
k
man
agem
ent.
hea
lthca
re M
anag
emen
t For
um, 5
(2),
23–2
9.
- M
urph
y, P
. F.,
Miy
azak
i, Y.
, det
wei
ler,
M. B
., &
Kim
, K. Y
.
(201
0). l
ongi
tudi
nal a
naly
sis
of d
iffer
entia
l effe
cts
on a
gita
tion
of a
ther
apeu
tic w
ande
r ga
rden
on
dem
entia
pat
ient
s ba
sed
on
ambu
latio
n ab
ility
. dem
entia
, 9(3
), 35
5–3
73.
- n
amaz
i, K
. h.,
& J
ohns
on, B
. (19
92).
Pert
inen
t aut
onom
y
for
resi
dent
s w
ith d
emen
tias:
Mod
ifica
tion
of th
e ph
ysic
al
envi
ronm
ent t
o en
hanc
e in
depe
nden
ce. a
mer
ican
Jou
rnal
of
alzh
eim
er’s
dis
ease
and
rel
ated
dis
orde
rs a
nd r
esea
rch,
7(1
),
16–2
1.
- W
hall,
a. l
., B
lack
, M. e
., g
roh,
c. J
., Ya
nkou
, d. J
.,
Kup
fers
chm
id, B
. J.,
& F
oste
r, n
. l. (
1997
). Th
e ef
fect
of
natu
ral e
nviro
nmen
ts u
pon
agita
tion
and
aggr
essi
on in
late
stag
e de
men
tia p
atie
nts.
am
eric
an J
ourn
al o
f alz
heim
er’s
dis
ease
& o
ther
dem
entia
s, 1
2(5)
, 216
–220
.
2Pr
ovid
e w
ande
r gar
dens
and
conv
enie
nt a
cces
s to
natu
ral e
lem
ents
.
Skilled Nursing
Assisted Living
Dementia/ Alzheimer’s Care
Strength of Evidence
res
iden
T sa
FeTY
ris
K a
sses
sMen
T M
aTr
iX
abstract v
resident Safety risk assessment
17results |
Res
iden
t S
afet
y O
utco
mes
Des
ign
Feat
ures
Key
Fin
ding
sR
efer
ence
sD
esig
n R
ecom
men
datio
ns
Med
ical
Er
rors
ligh
t lev
els
- Li
ght
leve
l. Ph
arm
acis
ts m
ade
sign
ifica
nt fe
wer
erro
rs in
dis
pens
ing
pres
crip
tions
whe
n ill
umin
atio
n
leve
l was
hig
her
(Buc
hana
n et
al.,
19
91).
Buc
hana
n, T
. l.,
Bar
ker,
K. n
., g
ibso
n, J
. T.,
Jian
g, B
. c.,
&
Pear
son,
r. e
. (19
91).
illum
inat
ion
and
erro
rs in
dis
pens
ing.
amer
ican
Jou
rnal
of h
ospi
tal P
harm
acy,
48(
10),
2137
–214
5.
1-2
impr
ove
illum
inat
ion
leve
l
in p
harm
acy
disp
ensi
ng
area
.
uni
t des
ign
to re
duce
inte
rrup
tions
- Int
erru
ptio
ns. Th
e nu
mbe
r of
inte
rrup
tions
and
dist
ract
ions
per
hal
f-ho
ur w
as p
ositi
vely
rel
ated
to t
he n
umbe
r of
dis
pens
ing
erro
rs p
er h
alf-
hour
(Fly
nn e
t al
., 19
99)
. Th
e ra
tes
of p
roce
dura
l
failu
res
and
med
icat
ion
erro
rs a
s w
ell a
s er
ror
seve
rity
wer
e po
sitiv
ely
rela
ted
to t
he n
umbe
r
of in
terr
uptio
ns p
er m
edic
atio
n ad
min
istr
atio
n
(Wes
tbro
ok e
t al
., 20
10).
- Fly
nn, e
. a.,
Bar
ker,
K. n
., g
ibso
n, J
. T.,
Pear
son,
r. e
.,
Ber
ger,
B. a
., &
sm
ith, l
. a. (
1999
). im
pact
of i
nter
rupt
ions
and
dist
ract
ions
on
disp
ensi
ng e
rror
s in
an
ambu
lato
ry c
are
phar
mac
y. a
mer
ican
Jou
rnal
of h
ealth
sys
tem
s Ph
arm
acy,
56(1
3), 1
319
–132
5.
- Wes
tbro
ok, J
. i.,
Woo
ds, a
., r
ob, M
. i.,
dun
smui
r, W
. T. M
., &
day
, r. o
. (20
10).
ass
ocia
tion
of in
terr
uptio
ns w
ith a
n in
crea
sed
risk
and
seve
rity
of m
edic
atio
n ad
min
istra
tion
erro
rs. a
rchi
ves
of
inte
rnal
Med
icin
e, 1
70(8
), 68
3–6
90.
1-2
red
uce
or e
limin
ate
dist
ract
ions
or
inte
rrup
tions
(suc
h as
nois
e, o
ther
unr
elat
ed
activ
ities
); se
para
te
phar
mac
y di
spen
sing
are
a
from
oth
er a
ctiv
ities
.
Hea
lthca
re-
Ass
ocia
ted
Infe
ctio
ns
(HAI
s)
roo
m
occu
panc
y
x- S
ingl
e ro
om. n
ursi
ng h
ome
resi
dent
s w
ith
indw
ellin
g ur
inar
y ca
thet
ers
wer
e th
ree
times
mor
e
likel
y to
con
trac
t ur
inar
y ba
cter
ia t
han
resi
dent
s
in s
ingl
e ro
oms
(Fry
klun
d et
al.,
19
97). n
ursi
ng
hom
e re
side
nts
who
se r
oom
mat
es w
ere
infe
cted
with
influ
enza
a h
ad h
ighe
r ris
ks o
f inf
ectio
n th
an
resi
dent
s in
sin
gle
room
s (d
rinka
et
al.,
200
3).
am
ong
nurs
ing
hom
e re
side
nts
who
dev
elop
ed
acut
e no
nbac
teria
l gas
troe
nter
itis
durin
g an
outb
reak
, 8
4% li
ved
in s
hare
d ro
oms,
onl
y 16
%
lived
in s
ingl
e ro
oms
(Peg
ues
& W
oern
le, 19
93).
- drin
ka, P
., K
raus
e, P
., n
est,
l., g
oodm
an, B
., &
gra
vens
tein
,
s. (2
003)
. ris
k of
acq
uirin
g in
fluen
za a
in a
nur
sing
hom
e fro
m
a cu
lture
-pos
itive
room
mat
e. in
fect
ion
con
trol a
nd h
ospi
tal
epid
emio
logy
, 24(
11),
872–
874.
- Fry
klun
d, B
., h
aegg
man
, s.,
& B
urm
an, l
. g. (
1997
).
Tran
smis
sion
of u
rinar
y ba
cter
ial s
train
s be
twee
n pa
tient
s w
ith
indw
ellin
g ca
thet
ers—
nurs
ing
in th
e sa
me
room
and
in s
epar
ate
room
s co
mpa
red.
The
Jou
rnal
of h
ospi
tal i
nfec
tion,
36(
2),
147–
153.
- Peg
ues,
d.,
& W
oern
le, c
. (19
93).
an o
utbr
eak
of a
cute
nonb
acte
rial g
astro
ente
ritis
in a
nur
sing
hom
e. in
fect
ion
con
trol
and
hos
pita
l epi
dem
iolo
gy, 1
4(2)
, 87–
94.
2Pr
ovid
e si
ngle
room
s.
clea
nlin
ess
and
ambi
ence
x- P
hysi
cal e
nvir
onm
ent.
cle
anlin
ess,
odo
rs,
nois
es,
hom
elik
enes
s, a
nd e
nviro
nmen
tal q
ualit
y (r
atin
gs
on T
hera
peut
ic e
nviro
nmen
t sc
reen
ing
surv
ey
for
nur
sing
hom
es)
wer
e fa
ctor
s as
soci
ated
with
low
er r
isk
of h
ospi
taliz
atio
n fo
r in
fect
ion
(Zim
mer
man
et
al.,
20
02)
.
- Zim
mer
man
, s.,
gru
ber-B
aldi
ni, a
. l.,
heb
el, J
. r.,
sloa
ne, P
.
d.,
& M
agaz
iner
, J. (
2002
). n
ursi
ng h
ome
faci
lity
risk
fact
ors
for i
nfec
tion
and
hosp
italiz
atio
n: im
port
ance
of r
egis
tere
d nu
rse
turn
over
, adm
inis
tratio
n, a
nd s
ocia
l fac
tors
. Jou
rnal
of t
he
amer
ican
ger
iatri
cs s
ocie
ty, 5
0(12
), 19
87–1
995.
1im
prov
e th
e qu
ality
of
ambi
ent e
nviro
nmen
t
(cle
anlin
ess,
hom
elik
enes
s, o
dors
,
nois
es, e
tc.).
Skilled Nursing
Assisted Living
Dementia/ Alzheimer’s Care
Strength of Evidence
res
iden
T sa
FeTY
ris
K a
sses
sMen
T M
aTr
iX
Not
e. S
ome
outc
omes
incl
uded
in th
is m
atrix
are
not
res
iden
t saf
ety
outc
omes
by
them
selv
es.
How
ever
thes
e ou
tcom
es s
tron
gly
impa
ct r
esid
ent s
afet
y. S
leep
dis
code
rs m
ay le
ad to
incr
ease
d fa
lls,
delir
ium
, m
orbi
dity
, an
d m
orta
lity.
Agg
ress
ion
and
disr
uptiv
e be
havi
ors
may
lead
to h
arm
to s
elf,
othe
r re
side
nts,
and
sta
ff. T
he s
tren
gth
of e
vide
nce
is in
dica
ted
by t
wo
num
bers
: 1-
som
e ev
iden
ce
(the
re a
re o
nly
one
or t
wo
stud
ies
with
wea
k st
udy
desi
gn/m
easu
rem
ent t
ool a
nd/o
r no
nsig
nific
ant t
ende
ncy)
; an
d 2-
Str
ong
evid
ence
(th
ere
are
mul
tiple
stu
dies
with
str
ong
stud
y de
sign
/mea
sure
men
t to
ol a
nd s
igni
fican
t res
ults
)
abstract v
resident Safety risk assessment
18 Conclusion |
resident Safety risk assessment
V. Conclusion
The built environment of LTC settings plays a significant role in providing safe
care to residents. Several of the environmental features mentioned in this paper are
especially important since each of them influences multiple resident safety outcomes.
Room occupancy: Single-bed rooms are related to better sleep, lower levels of •
agitation, and reduced risk of healthcare-associated infections.
Lighting: High lighting level is related to better outcomes—lower fall risk, •
lower agitation, and fewer medication errors. Bright light or sunlight exposure
at appropriate times helps reduce sleep disorders and disruptive behaviors.
Blocking afternoon sunlight together with a constant light level can lead to
reduction of disruptive behaviors.
Outdoor nature/wander garden: An outdoor nature/wander gardens •
contributes to the reduction of resident falls, agitation, and aggressive behaviors
and the improvement of sleep.
Acoustics: Sleep disorders and agitation/aggression can be reduced by •
alleviating noise and providing music or nature sounds.
Ambience: A soothing, homelike, aesthetic interior environment that provides •
positive distractions (e.g., nature artworks) may reduce agitation, aggression,
and unsafe exiting.
abstract v
resident Safety risk assessment
19references |
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25references |
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abstract v
resident Safety risk assessment
26author biographies |
VII. Author Biographies
resident Safety risk assessment
Anjali Joseph is the director of research at The Center for Health Design (CHD).
Trained as an architect, she has a doctorate in architecture from the Georgia
Institute of Technology, Atlanta, GA. Her work focuses on the relationship
between the healthcare built environment and healthcare outcomes. She leads and
coordinates the research activities at CHD. She also works closely with CHD's
member healthcare organizations called the Pebble Partners in developing their
research agenda, identifying research partners, and in communicating the results
of their research efforts through different channels. In addition, Joseph leads a
number of grant-funded research projects at CHD. Under her leadership, CHD
has received grants from the U.S. Green Building Council, Agency for Healthcare
Research and Quality, California HealthCare Foundation, the Kresge Foundation,
and others. In addition to authoring many papers for peer-reviewed journals,
Joseph is a regular speaker at national and international conferences such as
Greenbuild, Healthcare Design, and Institute for Healthcare Improvement. Joseph
served as a member of the Health Guidelines Revision Committee of the Facilities
Guidelines Institute for the 2010 cycle. She was voted among the top 25 most
influential persons in healthcare design in 2010 and 2011 in a survey conducted by
Healthcare Design magazine.
As a research associate for The Center for Health Design (CHD), Xiaobo Quan
works closely with the director of research to collaborate with Pebble Project
partners, planners, designers, and other researchers on Pebble Project research
efforts. He examines the impact of the built environment on human behaviors and
healthcare outcomes, evaluates the effects of evidence based design innovations, and
disseminates research findings through presentations and publications.
Quan has been actively engaged in healthcare environment research and has
published widely on topics of healthcare associated infection prevention, medication
anjali Joseph, Phd, edac
Xiaobo Quan, Phd, edac
abstract v
resident Safety risk assessment
27author biographies |
error reduction, patient safety, healthcare sustainability, work efficiency, patient
satisfaction and loyalty, cost-effectiveness and other topics. Previously, he worked
as a senior researcher, conducting healthcare environment research at Karlsberger
Companies. He also worked as an architect at East China Architectural Design &
Research Institute and Shanghai Xian Dai Architectural Design Group. He obtained
his Ph.D. in Architecture and a certificate in Health Systems and Design from
Texas A&M University, and his master’s and bachelor’s degrees in architecture from
Southeast University in Nanjing, China.