Lessons Learned: Commode Shower Chairs

February 6, 2018 | News


One of our member organizations has reported that over the past year-and-a-half, there have been three incidents of residents becoming jammed in the centre of a U-shaped commode/shower chair, while being showered. In two of the three incidents, emergency services were called to extricate the resident from the chair.

While emergency care was not needed following the incident, (only minor bruising, or no signs of physical trauma) it was a distressing experience, as the three residents have a diagnosis of dementia, and were unable to follow instructions. In each case, care aide staff was present, with two staff receiving muscle-strain injuries, and were off work as a result. The chairs in question were removed from use.

Inconsistent Equipment

At many homes, there is not presently a standardized shower/commode chair. There are different suppliers, with a variety of chairs. In addition, there is inconsistency in the design when it comes to the use of seatbelts, wheels, and opening at the front of the chair.

In the incidents noted above, the chairs had the U-shaped opening. In two of the cases, the chair was an older model and manufacturer unknown. In one case, the chair was less than a year old and manufactured by Drive Medical (product 660 NRS-185007)

Organization Follow-up

Due to the potential of psychological and physical trauma to residents and staff, these incidents flag risks that need to be addressed to ensure the safety and wellbeing of residents, particularly those with dementia and staff.

Following an investigation, the organization recommended:

  • Standardize commode/shower chairs to the closed seat design to prevent any possibility of this type of incident recurring
  • Staff be educated on resident diagnosis of dementia and ‘gentle care’ approaches so that showers and/or bathing do not cause major agitation.
  • Staff be educated on the use of seat belts with shower/commode and wheelchairs to ensure that seatbelts are appropriately fit and used (i.e. not loosely applied or used as an inappropriate restraint leading to a risk of strangulation)
  • All residents requiring seat belts in chairs to be assessed and fit by an Occupational Therapist to ensure safe use of this restraint
  • All U-shaped chairs be used only with residents able to respond consistently to verbal coaching,
  • A complete inventory of shower/commode chairs to be completed within six months