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. Emergency services were called to extricate the resident from the chair in two of the three incidents.

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

Many homes do not have a standardized shower/commode chair. There are different suppliers with a variety of chairs. In addition, there is inconsistency in the design regarding the use of seatbelts, wheels, and openings at the front of the chair.

In the incidents noted above, the chairs had a U-shaped opening. In two of the cases, the chair was an older model, and the manufacturer was 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 for psychological and physical trauma to residents and staff, these incidents flag risks that need to be addressed to ensure the safety and well-being 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 from recurring
• Staff should be educated on the resident diagnosis of dementia and ‘gentle care’ approaches so that showers and/or bathing do not cause significant 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 should 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