CMS Tag F741 Non-pharmacological Approaches – Adjusting the environment to be more individually preferred

CMS Tag 741 includes a long list of examples of individualized, non-pharmacological approaches to help meet behavioral health needs. We will be reviewing all of them. Food preferences, exercise, pain relief and individualizing sleep, dining and bathroom routines have been discussed in previous articles and now we highlight:

• Adjusting the environment to be more individually preferred and homelike (e.g., using soft lighting to avoid glare, providing areas that stimulate interest or allow safe, unobstructed walking, eliminating loud noises thereby reducing unnecessary auditory environment stimulation);

We will dedicate this article to lighting and I will use CMS’ own regulation as a guide.

CMS Tag F584 Safe, Clean, Comfortable Homelike Environment includes

-Adequate and comfortable lighting levels in all areas

DEFINITIONS §483.10(i)

 “Adequate lighting” means levels of illumination suitable to tasks the resident chooses to perform or the facility staff must perform.

“Comfortable lighting” means lighting that minimizes glare and provides maximum resident control, where feasible, over the intensity, location, and direction of lighting to meet their needs or enhance independent functioning.

I got to write a background paper contracted by CMS as the facilitator of the Creating Home National Symposium on Culture Change and the Environment called The Environmental Side of the Culture Change Movement available at my website edu-catering.com. I am going to just give my advice from what I’ve learned that we all could do to improve lighting. So all of the following is from my own authored paper which I recommend if you are interested in culture change and the environment.

In the famous CMS contracted study Measures, Indicators, and Improvement of Quality of Life in Nursing Homes which collect data from 1,988 people living in 40 nursing homes in five states, lighting levels were so low they approximated conditions of blindness according to a light meter. A light meter measures from 0, no light, to 10; the average measurement was 1. These measurements were found at the head of bed, sink and toilet in bathrooms, at nurses’ stations, in hallways and in showers which residents said were “dark, dank, and dismal.”  You may not have a light meter, but you have better, the people who live there who could tell you how well they can see in the various places in their home! This is what I would recommend.

Also, did you know you could call the local utility company, which will send someone out to measure light levels? What a great idea for a team interested in improving lighting.

The pupil gets smaller as we age allowing less light to reach the retina, which results in decreased vision. The aging eyes of a 60 year old require up to three times more light than 20 year old eyes. By the time we reach 75 as much as five times more light is often needed. Additionally, thickening and yellowing of the eye lens as we age can reduce the amount of light entering the eye.

Glare is a state in which bright light interferes with viewing something less bright. Glare and reflection can cause confusion, agitation and anger, inhibit activity and compromise safety. Glare is controlled by either increasing the brightness of the surroundings or decreasing the brightness of the source, or both. Surface brightness can be increased by illuminating the walls and ceiling and using lighter paint colors. Indirect light provides diffused light, which eliminates or reduces glare and contributes to visual comfort. Indirect lighting, lighting aimed toward the ceiling, is ideal rather than strong overhead direct lights.

None of us should look directly at a light source. Wheel people down the hall and have them look at the ceiling. Do they ever shield their eyes?

Day light is so very important. We know from our own experience that sunlight helps us sets our circadian rhythm, helps us sleep better, and improved mood for all of us. By the way, teach everyone that sun-downing means that person needs more sun and when you make it happen as a team, it helps the person and prevents agitation.

Sun-downing = needs more sun.

Seek to raise light levels, balance natural/day light and electric light to achieve even light levels and eliminate glare. Multiple lamps can also be used to create general ambient lighting.

Fun fact, did you know you can purchase light that is as bright as a sunny day? Sunlight averages 5200 to 5400 k (kelvin). You would purchase a bulb that states 5400 k. A standard warm white lightbulb is 3200 to 3500 k. Warm lighting tends to be more comfortable. These can be purchased just about anywhere and you just look on the bulb for the k measurement. Higher numbers of kelvin are stark white and very bright. These may be too bright light for most people but helpful for those needing more light.

Some homes still use fluorescent lighting which if it is too bright is very institutional and flickers which is hard on the average eye let alone the older eye. Also fluorescent light ballasts can be noisy. LED now provide adjustable brightness; warm to bright making it possible to match individual needs. An LED light uses much less electricity than a conventional light which saves money.

Did you know, turning a regular light switch into an adjustable one is not that difficult? (That’s what the cute maintenance manager says who I married when I was the activity director 34 years ago!) This can be helpful for dimming light when sleeping and also for being able to adjust light during the night to help get to the bathroom safely.

An LED bulb has a setting right on the base of the bulb you can set before you put into place. My hubby just grabbed one, you can set it anywhere from 2700, 3000, 3500 (warm), 4000, 5000 (sunlight-ish) and 6500 (whiter starker).

We also included the following practices regarding lighting in the Artifacts of Culture Change 2.0 (https://www.pioneernetwork.org/artifacts-culture-change/):

Artifact 65. The home makes available an extra lighting source in the resident’s room if requested by the resident such as floor or reading lamp. (Refer to CMS F584 Homelike Environment)

Artifact 66. Lighting throughout resident use areas is sufficient, according to the residents. (Refer to CMS F584 Homelike Environment)

Artifact 90. To provide safe travel between beds and bathrooms, night lights are used in resident rooms. (Refer to CMS F584 Safe Environment, comfortable lighting)

I hope you can advocate for better lighting in the LTC home where you work. At the very least, start asking people, bring up these facts, figures, and regulations at Resident Council, community or neighborhood meetings. Those who live there deserve adequate, comfortable and individually preferred lighting and these good regulations require it.

Carmen Bowman, MHS, Regulator turned Educator of Edu-Catering: Catering Education for Compliance and Changing Institutional Culture is an activities/engagement/community life, , regulatory compliance and culture change consultant.  She offers new or not-yet-qualified activity director consultation and personalized continuing education for professionals/teams/associations. At www.edu-catering.com join The Be Encouraged Blog, Become a Leader of Normal Life with the eResource GUARDIANS OF NORMAL LIFE: How Activity/ Recreation/ Engagement/Community Life Professionals can Save the World of LTC and share with your team the eBook Individualizing Medication Administration using Regulations. At the Edu-Catering YouTube channel, see documentaries that highlight changed cultures.