resident safety risk assessment - health design · resident safety risk assessment matrix ......

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 |


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


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


abstract v


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•


abstract

I. Summary of Literature Review

abstract v


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.

abstract v


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.


abstract v


4methodology |

III. Methodology


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.

abstract v


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 Falls

resident elopement/unsafe exiting

abstract v


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

abstract v


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


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

abstract v


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


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



res

iden

T sa

FeTY

ris

K a

sses

sMen

T M

aTr

iX

abstract v


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



res

iden

T sa

FeTY

ris

K a

sses

sMen

T M

aTr

iX

abstract v


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



res

iden

T sa

FeTY

ris

K a

sses

sMen

T M

aTr

iX

abstract v


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



res

iden

T sa

FeTY

ris

K a

sses

sMen

T M

aTr

iX

abstract v


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



res

iden

T sa

FeTY

ris

K a

sses

sMen

T M

aTr

iX

abstract v


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



res

iden

T sa

FeTY

ris

K a

sses

sMen

T M

aTr

iX

abstract v


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



res

iden

T sa

FeTY

ris

K a

sses

sMen

T M

aTr

iX

abstract v


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



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


18 Conclusion |


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


19references |

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abstract v


26author biographies |

VII. Author Biographies


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


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.

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