Assisted toileting and bathing options
Assisted is defined as help given or made available to another person. Assisted living facilities provide a much-needed service to senior citizens who may have difficulty with, or concerns about living on their own. Such facilities offer a safe place to live along with 24-hour assistance, healthcare services and activities that interest the residents. As the population of the US ages, the need for these types of facilities is increasing greatly.
The International Building Code (IBC) specifies that a percentage of assisted living, nursing homes and rehabilitation facilities offer fully Accessible units for a percentage of the rooms. This percentage increases based on the anticipated need. This percentage is 4% or 10% in the different types of Assisted Living (Group I-1, Condition 1 and 2; IBC Section 118.104.22.168); 50% in nursing homes and 100% in rehabilitation facilities (Group I-2, Condition 1; IBC Sections 122.214.171.124 and 1107.5.4). The technical standard referenced for the “how to” is the ICC A117.1 Accessible and Usable Buildings and Facilities (ICC A117.1; Section 1002). However, the main purpose for the ICC A117.1 states “The intent of these sections is to allow for a person with a physical disability to independently get to, enter and use a site, facility, building or element.” While allowing for individuals to maintain their independence is very important, many of the elderly residents in assisted living and nursing facilities no longer have the physical strength or stability for these options to safely work for them.
The Mayer-Rothschild Foundation has completed research that has recommendations for the ideal dimensions for grab bars and toilet spacing for assisted toileting. To allow for staff to be on either or both sides of the resident for assistance in standing, sitting or transferring, the toilet must be farther from the wall than what is required in the ICC A117.1. This research shows that lifting from the sides is safer both for the staff and the resident. This same concern for staff to be able to get to all sides of the resident also spurred different configurations for roll-in showers.
The ICC Committee on Healthcare Committee (CHC) used this research to develop successful proposals for the 2021 IBC. Code changes (E123-18, E124-18, E125-18) have allowed for bathrooms that offer assisted toilet and bathing facilities in a portion of the patient rooms required to be Accessible units. For assisted living facilities, the allowance will be that half of the Accessible rooms can have the configurations for assisted toileting and/or bathing. For nursing homes and hospitals, 90% of the Accessible rooms can use this option.
The CHC also requested that the technical provisions for assisted toileting and bathing be added to the 2021 IBC (E128-19 and E129-19). What was approved is illustrated in Figures 1, 2 3 and 4. While the CHC would have liked to propose these technical criteria to the ICC A117.1 committee, the research was not completed for consideration during the development of the 2017 edition of the ICC A117.1. The CHC does plan to propose this to the A117.1 in their next development cycle. However, it was felt that the industry needs this critical information now, and cannot wait until the next edition of the ICC A117.1 is completed.
The intent of the assisted toileting provisions are to allow space for a side transfer from a wheelchair, however, the water closet is farther from the adjacent wall. Since a wall mounted grab bar would now be out of reach, two fold-down grab bars are required. Research has proven that the use of fold-down grab bars on both sides of the toilet is safer and easier for older adults who transfer independently. In addition, residents in care settings who need staff assistance to transfer on/off the toilet need more space between the toilet and the wall to enable a staff person (or two) to fully assist a person without risk of injury to the resident or caregiver. The additional space at the toilet would also allow for better access with many types of lifting devices.
The key part the assisted bathing option is to remove the requirement for permanently installed folding or fixed seats from a roll-in shower configuration and have grab bars on three walls. No fixed seat also allows more options for locations of the water controls. These wall mounted seats do not work well when residents are being assisted with showering. The wall mounted seats make it challenging for care-givers to access the back and one side of the resident they are bathing. Most often, if residents cannot stand for bathing, a portable, rolling chair is used and the folding seat stays folded up (but takes up space). This new configuration allows the care-giver greater access to all sides of the resident. In addition, the rolling chair is often easier to transfer to for older adults, than a wall mounted seat. This proposal also recognized alternate shower configurations that provide equal, if not better accessibility. For example, many nursing homes provide a “European” shower where two sides are open to the bathroom. This provides greater access for both resident with mobility issues as well as the care-giver. Water can be managed with shower curtains, either on a curtain track or an “L-shaped” curtain rod, however usually the entire room is designed to be a “wet room”.
It is the opinion of the CHC and others that have reviewed these new options, that this will be viewed as designs that are specific to the needs of the population they serve, and therefore meet or exceed the intent of the Accessible unit options in the ICC A117.1 and the 2010 ADA Standard for Accessible Design.
There is not a concern for the assisted toilet and bathing facilities to be in conflict with the Type B units required in these facilities (IBC Section 1126.96.36.199, 1188.8.131.52), because the provisions addressed in this new option would be permitted under the current requirements for Type B units (ICC A117.1 Section 1004). These provisions provide a higher level of accessibility than required in the Fair Housing Guidelines.
With a little assistance, we will all get by with a little help from our friends.
Lee, S.J., Sanford, J., Calkins, M. Meglen, S., Endicott, S. & Phillips, A. (2017) Beyond ADA accessibility: Meeting seniors’ needs for toilet transfers. HERD. DOI: 10.1177/1937586717730338
Click here to view the code change proposals for 2019. Search for the code changes in Group A, Proposed Changes to the I-Codes and the Report of the Committee Action Hearing.