Design for living: safely and securely.

NURSING HOME DESIGN HAS TO KEEP PACE WITH RESIDENTS' NEW NEEDS

Because people are living longer, and the elderly are staying in nursing homes for more protracted periods, their quality of life in these facilities becomes increasingly important. To deal with this challenge, architects are concentrating more on de-institutionalizing nursing homes. And for safety and security, this has major ramifications.

The best way to insure residents' safety and security is to minimize two particulars: the opportunity to wander and their exposure to the risk of injury. Many nursing home patients are all too vulnerable on both counts.

The impulse to wander is a strong one. Elderly people like to roam, but they prefer to do so in a familiar environment. And there's nothing wrong with this, if it's supervised carefully. One element of this is proper attention to a home's interior design, which can minimize dangerous wandering.

In approaching this challenge in the facilities we design, we design and decorate each nursing unit of about 40 patients with both a distinct character and a specific color scheme. These extend to the carpet, walls, tiles, and even the furniture. This not only provides a resident with a feeling of proprietorship, but reinforces his or her identity of the unit. This, in turn, helps to reduce the amount of meandering into neighboring areas.

To accommodate residents' innate desire to wander -- while keeping it under strict control -- we have been recommending an extended use of alcoves and seating areas off corridors. They are generally visible to staff monitoring the facility. Another relatively new phenomenon is wider corridors, which provide enough space for seating areas in plain view of nurses' stations.

Not only do such accommodations permit staff to observe the residents, but the patients themselves tend to prefer to be where things are happening. For architects, it is essential to take into account the residents' need to be around others.

We've found, for example, that a quiet room with a splendid view will no longer appeal to a nursing home resident, as it would have 20 years earlier, when he or she lived in a house with a family. Nursing home residents would simply rather sit with others, even if the view isn't as majestic as it is from their own rooms. As a result, our designs today tend to stress resident-activity areas that are closer to the floor's core -- i.e., the nurse's station control areas.

An even more severe problem in nursing homes is, of course, the growing number of residents with Alzheimer's disease. For them, wandering is a particularly frequent -- and progressively worsening -- problem. Accordingly, we like to design for them a layout that is subtly circular, so that if they roam, they will tend to return to where they started, within the boundaries of their own nursing unit.

Another method to increase resident safety is by providing tactile references on handrails and hardware. A textured door handle, or a knob on the end of a hand rail, will help patients recognize which areas are off-limits or orient them to their surroundings.

Sometimes, two desirable goals will conflict. For example, complying with a fire code may impede the control of wandering. Typically, fire codes don't allow emergency doors to be locked. In a nursing home, a patient wandering through one of these doors will trigger an alarm system. But sometimes nursing homes can obtain permission from the proper authorities to lock these doors and have them open only when prompted by smoke detectors, fire alarms or a switch at the nursing stations. In such cases, we suggest installing an override button somewhere on each door, accessible only to the staff.

Wandering is only one aspect of safety, of course. Others must be addressed as well. For example, we pay considerable attention to the materials we use. Thus, we usually recommend bumpers on walls and on the corners of beds, and no metal protrusions. If privacy curtains are used around a bed, they should be designed with sufficient strength to physically support the patient. And, of course, handrails are vital in showers. Of course it is standard to have hand-rails throughout the nursing home, but they should be considered for outside use, as well, for the safety of patients as they traverse the grounds.

One development that is promoting safety is the recently enacted Americans with Disabilities Act (ADA). Nursing homes built under this law offer a much safer and more easily-traveled environment for residents with sight and hearing disabilities, as well as those in wheelchairs, than do many of those that predate the law. Also, such equipment as fire alarms with strobes are becoming standard.

While the intended beneficiary of ADA is the handicapped, the new law will also help other residents as well. For example, such benefits as larger rooms to accommodate wheelchairs will result in a better quality of life for everyone, not just the handicapped.

One problem that administrators and architects must face when trying to comply with the new ADA codes is deciding between renovation vs. new construction. While simply building a new facility or constructing an addition to an existing one may be ideal, it's not always possible or affordable. In a heavily urban area, for example, there may not be enough space. And even when sufficient space does exist, renovation may not make sense because of excessive cost.

If you choose renovation, though, be sure your architect holds extensive meetings with those operating the facility and with the staff. This is crucial to the ultimate safety and security of a nursing home. It's one thing for the architect to comply with the code; it's another to put yourself in the shoes of the residents, a perspective that only those who work with them daily can supply. Unfortunately, it's often overlooked in the architects' eagerness to provide an aesthetically pleasing plan.

Another safety issue involves crime. In nursing homes, as in apartment houses, some residents as well as staff have criminal tendencies. Locks for residents' closets are essential.

We also insist that reception areas be equipped with television monitors, so that those on duty may observe the parking lots and entrances to the buildings. In general, we recommend that exterior patient-activity areas be kept separate from parking lots with the use of railings, shrubbery, etc. Furthermore, the entire facility should be fenced-in and secured, with video cameras for surveillance and, perhaps, a guard post at the entrance.

Similarly, because kitchen, delivery and supply areas are attractive to burglars, we design them so that equipment can be locked and exits monitored.

Other suggestions for maximizing safety and security include placing:

* a gate at the top of stairways, to prevent residents from going to the roof;

* alarms at all roof doors;

* numerous call bells in toilet rooms, showers, patients' beds and resident-activity areas;

* a stop on all windows, to prevent residents from climbing or falling out (resident window sills should be high enough to keep patients from falling into the glass and out the window);

* ground fault interrupters (GFIs) on outlets near sinks, lavatories or toilets, to prevent residents from receiving an electric shock (a GFI will produce a short instead);

* night lights for all patient rooms; and

* flame-resistant materials for all resident curtains and draperies.

Having designed nursing homes for 25 years, I've noticed remarkable changes. When I started out, nursing homes were more like hospitals, and residents enjoyed only a very limited amount of space in their rooms. Activity areas were small and scarce. One of the only amenities was the dining room. Residents tended to be tucked away behind closed doors in a formal room. Unless a nurse looked into the room, she did not know how the resident was faring.

Today matters are entirely different. Generally speaking, nursing homes now are much more concerned with the residents' quality of life. People are living longer. If their bodies are deteriorating, their minds are active; sometimes, it's the other way around. Areas must be provided for arts and crafts, playing games, learning games -- in short, you need much more than merely a dining room. And, of course, the handicapped must be attended to. In general, the aim today is to enhance the patient's quality of life through physical and mental activity.

For the designer of nursing homes, the implications of even as simple an activity as eating have changed drastically since I began. Back then a nursing home resident had to get on an elevator -- and get off an elevator -- three times a day just to get to the dining room. But today, dining areas are much more plentiful in a home, and tend to be closer to the residents. Indeed, in many cases, residents no longer have to leave their floors at all in order to eat. As a result, safety, convenience and security are greatly enhanced.

In general, the aging of the nursing home population is the major challenge administrators face in the '90's and beyond. The solutions, though, are already on the drawing boards.

Jerrold Clarke, AIA, has spent his entire 25-plus-year career working with nursing homes and hospitals and is with the Manhattan-based architectural firm of Schuman Lichtenstein Claman & Efron.