Long-Term Care Survey Alert

Expect surveyors to take a closer look not only at how you’re bathing residents, but how residents are responding to the bath-time experience.

The Centers for Medicare & Medicaid Services doesn’t dictate how nursing facilities are required to meet residents’ hygiene needs. “The regulations enhance supporting quality of life while providing necessary care,” said CMS policy analyst Karen Schoeneman during a recent CMS Webcast on quality of life in nursing homes. And as a first step toward improving quality of life and care, many facilities are creating more visually pleasant spaces for their bathing areas, said Webcast speaker JoAnne Rader, a nurse researcher and associate professor of nursing at Oregon Health Sciences University. “That’s good but not enough,” Rader emphasized. “Our attitudes about bathing residents need to be examined.”

A Chilling Experience

For Rader, new insights about how residents might experience the bath came from having a nursing assistant give her a shower in a nursing home.

Although the aide did a good job, Rader felt “naked and exposed” and found out there’s a “breeze on your backside” when you go down the hall in the shower chair, even when you’re covered up. “And when someone else controls the water, it’s uncomfortable,” she noted, “like you can’t breathe.”

As a result of her experience, Rader advises helping residents stay warm by covering them during the shower with towels. “You can also turn on the warm water before you bring the person in or use a heat lamp” to warm the air, she suggested.

Rader also noted her feet turning bluish purple during the shower, a phenomenon she’d always attributed to poor circulation in elderly residents. But since she doesn’t have poor circulation, Rader realized that poorly fitting shower chairs are the real cause of the color change.

Staff can, however, pad the chairs using wash cloths or towels. Or use inexpensive pipe insulation for residents with sensitive skin. “A children’s potty seat insert will keep the resident’s tender hip bones from pushing on that hard surface,” Rader suggested.

To prevent the resident’s feet from dangling painfully, place a small stool under his feet. Or turn a regular wash basin into a stool by turning it upside down and placing the resident’s feet on top.

Rader also asked staff to identify people with dementia who battled the bath. Using a trial and error method, she found that most people with dementia have a hard time tolerating running water. And some of them interpreted the bath as a life-imperiling experience. “One resident through she was being lowered into a hog pit to be boiled,” Rader recounted. Or residents with dementia may feel sexually assaulted by the bath experience, in some cases. After making these discoveries, Rader developed a no-rinse bed bath that greatly relieved dementia residents’ distress in almost all cases, and reduced aggressive bath-time behaviors by half.

Getting Clean the Comforting Way

Before administering the no-rinse bath, Rader tells the resident she’s going to give her a nice warm massage. Rader then undresses the resident to the extent the resident permits and covers her with a warm bath blanket.

Next she prepares the following materials:

• A plastic bag;

• Regular-sized towel;

• A couple of wash cloths;

• A large beach-sized towel.

• An ounce-and a half of no-rinse soap in a pitcher with three liters of water.

Rader’s favorite soap is one with a soybean and coconut base that moisturizes the skin and removes debris. The trick to providing a pleasurable bath experience is to ensure the resident stays warm and covered throughout the process. “And keep in mind that the bath is also about relationship, attitude, communication and flexibility,” Rader emphasized.

To give the bath, lift up the bath blanket and cover the resident with the warm towel. You can leave the bath blanket on to keep the heat in.

Use the wet towel with soap solution as a giant wash cloth. Ask the resident to bend her knees and wash the surface of the body. If she is able to roll on her side, ask her to do so. Place one of the wet towels on her back and use it to wash and massage the back.

Once the resident is clean, remove the wet towel and dry her thoroughly.

Does the no-rinse bath really get residents as clean as the shower or tub bath? Rader did follow- up research to answer that question. “We cultured the residents’ axillary and inguinal areas for odor-causing bacteria and did an overall skin assessment,” she reports. Not only did Rader find no increase in pathogenic bacteria, but the residents’ skin condition was actually better than before.

Time Requirements a Wash

The individualized shower took 3.5 minutes longer than the routine shower, Rader reports. But staff found that dressing the resident afterward was much easier. And the towel bath took 1.6 minutes longer, although staff made up that time by not having to transport the resident to the bathing area.

“And if caregivers give good morning and evening continence care, some residents may not need or want a shower more than once a week, so you can spend more time making that weekly experience a better time for the resident,” Rader noted.