Q: Do linen chute doors have to be locked? Our risk manager says they are required to be locked, but I don’t see anything in the LSC that says that. What are the requirements for chute doors in regards to the LSC?
A: I will assume you are referring to an existing occupancy. There is no requirement in the Life Safety Code to lock linen (or trash) chute doors. Also, there are no direct standards from Joint Commission, HFAP or DNV that require locks on linen (or trash) chute doors. Where hospitals get into trouble with this issue is failing to assess the perceived risk. Any surveyor or inspector can look at a chute door that is not locked and ask to see the risk assessment that allows the door to be left unlocked. The perceived risk is that an unauthorized individual may open the door and fall into the chute. An assessment could analyze that risk and determine if it is a low, medium or high risk for that particular area. If the chute door is located in an area where there are children, patients or visitors, then the risk is naturally higher than in areas where there are no children. Other factors must be assessed as well, such as behavioral health or Alzheimer’s units, forensic units and unsupervised areas. Whenever a risk assessment is conducted, make sure you include a wide variety of stakeholders in order to gain a well-rounded perspective. Once the assessment is completed, have your Safety Committee review it and approve it, and get their decision posted in the minutes. For new construction, access to linen and trash chute doors must be within a room, and either the chute door or the access room door must be locked, but not both.