Jan 02 2017

Addressing Common Misconceptions Regarding Corridor Doors

Category: BlogBKeyes @ 12:00 am
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Corridor doors are one of the most common components of the means of egress, yet their significance is often overlooked, possibly because there are so many of them in a hospital. This article will address the different concerns and issues surrounding corridor doors in a healthcare occupancy that may not be considered common knowledge.

The Life Safety Code (LSC) does not require corridor doors to patient rooms to have closers, but if they do have closers, then they can have the type that have hold-open friction-catch closer arms, that requires someone to physically close them.  Hospitals are defend-in-place facilities, so the question asked by some is why do we rely on people to accomplish the closing of the door rather than allow a closer to do it?

As mentioned, corridor doors to patient rooms are not required to have closers, and this is in accordance with section 19.3.6.3.11 of the 2012 LSC. But the Annex section of 19.3.6.3.5 says the concept of having corridor doors to patient rooms without closers allows staff to visibly see into the room to detect any fire or smoke condition. If the door had a closer, then the Annex section recommends the room be protected with a smoke detector. The basic premise of a healthcare occupancy is there is adequate staff on hand to make these observations.

Which brings us to the issue of those patient room corridor doors that have signage added, and coat hooks applied; would they be considered acceptable?

Coat hooks on a non-fire rated patient room corridor doors would be allowed. But a coat hook on a fire-rated door typically would not be acceptable (even if it is applied with adhesives) because any garments hanging from the coat hook would likely contribute to the fuel load of the door. But signage that was informational (i.e. contact precautions; oxygen administered; diet restrictions, etc.) would be permitted, even if they were combustible.

Are corridor doors that are located in a 1-hour fire barrier permitted to be only fire-rated for 20 minutes and not ¾-hour? The answer is no. If a corridor door is part of a fire-rated barrier that serves some other function, such as a vertical opening, exit, or hazardous area, then it must meet the most restrictive requirements of either. But where corridor doors are located in a 1-hour fire-rated barrier the corridor door must be at least a ¾ hour fire rated door, mounted in a fire-rated frame, with self-closing and positive latching hardware. Vertical openings are elevator shafts, mechanical shafts, stairwells, and the like. Exits are direct exits, horizontal exits and exit passageways. Hazardous areas are storage rooms >50 sq. ft. containing combustibles, soiled utility rooms, fuel-fired heater rooms, laundries >100 sq. ft., paint shops, repair shops, trash collection rooms, laboratories, and medical gas rooms (storage rooms with >3,000 cubic feet of compressed gas).

There is one exception to the above rule where a corridor door located in a 1-hour fire rated barrier must be ¾ hour fire rated: When the corridor door is also located in a 1-hour barrier separating the corridor from an atrium. According to section 8.6.7 (1) of the 2012 LSC, the atrium must be separated from adjacent areas with a 1-hour fire rated barrier, but the openings in the 1-hour fire rated barrier are only required to be same as is required for corridors. This means the doors in the atrium separation could be non-rated and only required to resist the passage of smoke, since atriums are only permitted in fully sprinklered buildings.

However, I don’t see where a patient room door would be part of any of these fire-rated barriers, although a patient room door could be part of a smoke barrier, separating smoke compartments. Even though the smoke barrier is required to be 1-hour rated, it is not a fire rated barrier, because the doors in a smoke barrier are only required to be 1¾ inch thick, solid-bonded, wood core doors, or of such construction to resist fire for at least 20 minutes, and must be self-closing. They are just like corridor doors in a non-sprinklered smoke compartment, but must have closers on them.

It’s important to realize that not all corridor doors have to meet the NFPA 80 requirements for fire-rated doors. However, if the corridor door is a fire-rated door, it must be compliant with the requirements of NFPA 80. If the door has a fire rated label, then it is a fire-rated door, and it must be mounted in a fire-rated frame, equipped with a self-closing device, and have positive latching hardware.  The problem that I observe in many hospitals is they installed labeled fire-rated doors in walls and barriers that are not fire rated. Therefore, even though the wall or barrier is not required to have a fire-rated door, the fact that the door is fire-rated means the organization must maintain it as such, according to section 4.6.12.3 of the 2012 edition of the LSC. So, if you have a fire-rated door in a corridor wall, and the corridor wall is not required to be fire-rated, then you must still maintain the fire-rated door to the requirements of NFPA 80, which includes annual testing.

Where I often find this problem in hospitals is the smoke compartment. Some designer/architect sees that smoke barriers are required to be 1-hour rated so they specify ¾ hour fire rated doors. Again, a smoke compartment barrier wall is not a fire-rated wall; therefore, the conditions of 19.3.7.6 apply where 1¾ inch thick, solid-bonded, wood-core doors are allowed. Also, some designers/architects see that smoke barrier doors that are of such construction that resists fire for at least 20 minutes are permitted, so they specify 20-minute fire rated doors for smoke barrier openings. Again, this is not required to have fire-rated doors, but since the 20-minute fire-rated doors was installed, you must maintain it to NFPA 80 requirements, which means it must be mounted in a fire rated frame, be self-closing, and positive latching. I see a lot of 20-minute fire rated doors in smoke compartment barriers that do not have positive latching hardware, which is non-compliant with NFPA 80. The organization must maintain the door to NFPA 80, or simply remove the fire rated label, then the door is no longer a fire-rated door that is obvious to the general public, and does not need to be maintained as such.

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Feb 19 2016

Required Width of an Excess Access Corridor

Category: BlogBKeyes @ 12:00 am
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Q: What is the required width for an exit access corridor in an office building?

A: That depends on the occupancy classification of the building. If the building is classified as business occupancy, then sections 38/39.2.3.2 of the 2000 Life Safety Code (LSC) would apply. The clear width of an exit access corridor in a business occupancy (office building) serving an occupant load of 50 or more, is 44 inches. But for occupant loads less than 50 persons, section 7.3.4.1 of the LSC would apply and the clear width is lowered to 36 inches.

When the Life Safety Code talks about the occupant load of a room or area, it is always calculated per section 7.3. Table 7.3.1.2 has occupant load factors that are used along with the gross area to determine the number of persons allowed. For a building classified as business occupancy the occupant load factor is 100 square feet per person. This means in order to have an occupant load of 50 persons you need 5,000 square feet of area.

If the office building is classified as an ambulatory health care occupancy, then according to section 20/21.2.3.2, the required width of the corridor is limited to just 44 inches. There are no deviations for less than 50 occupants.

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Nov 06 2014

A Follow-Up to “Comments on Corridor Clutter”

Category: BlogBKeyes @ 6:00 am
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The following comment is a result of an article that I ran last August on corridor clutter (search: Comments on Corridor Clutter), which quoted Randy Snelling, the Chief Physical Environment Officer for DNV.GL Healthcare, Inc. This comment is from a representative from a state agency that performs surveys on behalf of CMS.

First, I totally agree with both Randy and you. Both in principle and standard we should be  more up to date and facilities should know what the standard is and how to  follow it. Oddly, I spend more time assisting facilities on this issue even when I cite it. I tend to smile when they announce I have arrived and wonder “Were you in compliance yesterday?”

As a surveyor doing checks on all occupancies, I have found none ever seem to not have some issue with space and where to place those items needed for patient/resident care. Having worked in a healthcare facility, I can also fully relate that focus being first and foremost.

That being said, the standard is there for a reason and has been for some time.  Even though my initial peek into 2012 finds some increasing awareness of how clutter is viewed, I still believe that we have a wide arrangement of options if, as both you and Randy point out, senior management buys into it and
supports either their Safety Manager or Maintenance staff.

Inevitably, these are the ones who take it very personally when I cite a facility for a blocked or obstructed corridor. Administrators, Chief Nursing Officers on down need to understand the reasoning behind the code and what steps it takes to stay in compliance. I feel a majority of the time the facility management thinks “Oh we clear everything when the drills happen”. Now imagine those corridors filled top to bottom with smoke. The scenario will change considerably. I hope all who read your article and Randy’s comments take it to heart.

I think this representative for a state agency makes a very good point: The healthcare industry needs better education on the need to keep the corridors clear from clutter. I suspect we have become insensitive to this issue because the frequency of fires in hospitals has dropped dramatically since the mid-1980’s, when smoking was restricted in hospitals.

But fires still occur in healthcare settings as documented in either this blog or in the HCPro’s Healthcare Life Safety Compliance newsletter. And it is the belief of Randy and I (and this representative from a state agency) that corridor clutter still needs to be taken seriously.

In my opinion, it did not help that the NFPA Life Safety Code technical committee decided to allow certain unattended items in corridors of 8 feet as described in the 2012 edition. It also didn’t help that CMS decided to endorse this section of the 2012 edition last year as a categorical waiver. The decision on the technical committee to do this was not unanimous, as a representative from a state agency who surveys hospitals (not the same individual quoted above) enthusiastically opposed the decision. Since he had first-hand observation on how hospitals abuse codes and standards, he did not want to allow them to store items in the corridor.

I suspect corridor clutter will remain a problem until senior leadership decides to take an active role in resolving it.

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Aug 28 2014

Comments on Corridor Clutter

Category: BlogBKeyes @ 6:00 am
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Randy Snelling, the Chief Physical Environment Officer, for DNV-GL Healthcare Inc. spoke at the recent ASHE annual conference in Chicago, and I thought his views on corridor clutter were worth repeating here…

“I read in the ASHE magazine recently an article written by a surveyor who listed the top 5 findings he saw during a survey”, says Snelling. “The first thing he identified was corridor clutter. I threw the magazine across the room. I thought, ‘Man, where are we? This is 2014 and we’re still talking about corridor clutter? Really? Come on!’ Why is corridor clutter still happening in hospitals? Because the senior leadership is not stepping in. The facility manager does not have the clout with those clinicians up on the floors where the corridor clutter occurs. But who does? Senior leadership. And if you’ve got corridor clutter problems, it’s not a life safety problem, it’s a ‘C’ suite problem. And our hospitals know it. I don’t think we’ve had a corridor clutter finding in over a year. Now, what happens? Well, we come in and the hospital makes an announcement overhead welcoming the DNV survey team, and everything gets moved out of the corridor. But that happens with everybody else too, with HFAP and TJC and CMS. So why are we seeing this? I think it is because since we are in the hospital every year our hospitals do not have as much to move out of the corridors as other accredited hospitals. This ends up being a problem with Leadership rather than a problem with the facility manager.”

I consider Randy to be a friend and we talk frequently about accreditation issues. I think his view on corridor clutter on the nursing units is spot on, in that senior leadership needs to back the facility manager (or safety officer) on Life Safety Code issues that are out of their capability. Having been a Safety Officer at a hospital for years I can relate to this problem. I rarely felt the support from the ‘C’ suite and felt I had to struggle with certain basic life safety requirements (such as corridor clutter) on my own.

I did eventually take a different approach by spending time on the nursing units observing the nurses day-to-day operations. This made me realize their needs better and they eventually saw me as one who wanted to help, rather than the enemy who was always telling them to move their equipment out of the corridors. I was able to apportion capital funds to build alcoves in certain locations, and they in turn kept the corridor free from clutter.

But most hospitals probably still struggle with corridor clutter issues and without the senior leadership stepping in and backing the facility manager by insisting items be stored in alcoves and storage rooms, this problem will not go away. I predict it will get worse when the 2012 Life Safety Code is finally adopted, since the new LSC allows certain unattended items to be placed in corridors that are at least 8 feet wide. That will create a struggle for everyone as most staff will not understand what pieces are permitted and what pieces are not permitted.

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Aug 14 2014

Corridor Doors vs. Cross-Corridor Doors

Category: BlogBKeyes @ 6:00 am
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Cross Corridor door web 2I have seen many facility managers (and surveyors for that matter) incorrectly refer to a door as a ‘corridor door’. It appears that they believe as long as the door is accessible from the corridor, then it must be a corridor door. That is not always the case, but it is understandable as corridor doors may be confusing.

A corridor door is a door that separates a room from a corridor, and they are usually mounted parallel to the corridor. Corridor doors are often found on entrances to patient rooms, utility rooms, offices, dining rooms, and the like. Corridor doors are often (but not always) a single-leaf door.

A cross-corridor door is a door that separates a corridor from another corridor, and they usually are mounted perpendicular to the corridor. They are typically used as privacy doors, smoke compartment barrier doors, and fire-rated doors in a horizontal exit or an occupancy separation. Cross corridor doors are usually (but not always) double-leaf doors, and if considered new construction, must be double egress, meaning one leaf swings in one direction and the other leaf swings in the opposite direction.

In reviewing accreditation organization survey reports, I have read where surveyors often refer to ‘corridor doors’ when they really mean something else. According to the Life Safety Code, a corridor door is not required to have a self-closing device (closer), unless it also doubles as a door to a hazardous room, a smoke compartment barrier door, or a fire-rated door. Also, a corridor door must latch, while a smoke compartment barrier door does not have to latch. If a door serves more than one purpose, then the most restrictive requirements must apply.

When referring to the many different types of doors that are accessible from the corridors, always refer to them by their most restrictive requirements:

  • Fire-rated doors to hazardous rooms, exit enclosures, horizontal exits, and occupancy separations
  • Smoke compartment barrier doors
  • Corridor doors to hazardous rooms, or non-hazardous rooms
  • Privacy doors

A privacy door that is a cross-corridor door is not required to latch, or be self-closing; but a privacy door that is a corridor door would be required to latch, since the requirements for a corridor door are more restrictive.

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Jul 31 2014

Smoke Compartment Barrier Door Gaps

Category: BlogBKeyes @ 6:00 am
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Smoke compartment barrier doorsI want to clarify a confusing point in the seven-year old CMS S&C memo 07-18 issued April 20, 2007. This is a memo which CMS wanted to explain that corridor doors that are not fire-rated or used in a smoke compartment barrier are permitted to have gap clearances up to ½-inch in smoke compartments that are protected with sprinklers. In this memo they have conflicting points; the subject line of the memo stated: “Permitted Gaps in Corridor Doors and Doors in Smoke Barriers”, but in the content of the memo they say “This information does not apply to doors in smoke barriers, which have other requirements.”

Click on this link to access this CMS memo:  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/CMS1198675.html?DLPage=1&DLFilter=07-18&DLSort=3&DLSortDir=ascending

To be clear, the maximum gap for the proper clearance of smoke compartment barrier doors is 1/8 inch; not ½ inch, and it is not dependent on whether or not the smoke compartment is sprinklered. Sections 18/19.3.7.6 of the 2000 LSC references section 8.3.4 of the same code and the Annex section of 8.2.4.1 says the maximum gap for smoke compartment barrier door clearances is 1/8 inch.

The CMS memo addressed corridor doors that are not fire-rated or located in a smoke compartment barrier. Corridor doors are those doors which separate a room or an area from the corridor. Can a corridor door also be a fire-rated door or a door in a smoke compartment barrier? Yes, certainly; and in those situations the more restrictive requirements must apply.

The bottom line: Doors in smoke compartment barriers must not have gap clearances that exceed 1/8 inch per the 2000 LSC. The CMS S&C memo 07-18 only applies to non-fire-rated corridor doors that are not located in a smoke compartment barrier.

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Aug 22 2013

Alcoves and Areas Open to the Corridor

Category: BlogBKeyes @ 5:00 am
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Alcove Web 2When does a wide spot in the corridor have to meet the requirements for areas open to the corridor? This question was raised to me in regards to a clean linen cart parked in an alcove of the corridor. Does it have to comply with the section on corridor width or the section on areas open to the corridor? This is just one more example of an issue that is not clearly defined in the Life Safety Code and as best as I can tell, the answer lies with the authority making the interpretation of the code.

First we need to understand the two issues. According to section 18.2.3.3 of the 2000 edition of the LSC, corridors in areas that are intended for the housing, treatment or use of inpatients in new construction healthcare occupancies are required to be no less than 8 feet wide in clear and unobstructed width. In areas where inpatients are not expected to use the corridors, the clear and unobstructed width is required to be 44 inches. Corridors wider than the required width are permitted to have alcoves that contain non-combustibles as long as the alcove area does not exceed 50 square feet, and does not encroach on the required width of the corridor. If it exceeds more than 50 square feet, then the area could be classified as a hazardous area if it contained combustibles, and clean linen would most certainly be classified as combustible. So, the alcoves need to be no more than 50 square feet, if they are going to contain clean linen carts.

According to section 18.3.6.1, areas open to the corridor must comply with a variety of requirements, which includes smoke detectors. But if the alcove is considered a wide spot in the corridor, then it would not have to comply with section 18.3.6.1 and have smoke detectors. So, the question remains: When is an alcove just a wide spot in the corridor and when does it have to meet the requirements for 18.3.6.1 and have smoke detectors?  And if we are asking the same question for existing conditions, it gets a bit more complicated as sprinklers may or may not be required.

Anyway… When the Life Safety Code is not clear, then the answer is up to the authority having jurisdiction to make an interpretation and rule on the issue. The LSC actually says that (in so many words) in section 4.6.1.1. So, if I were the AHJ, I would say an alcove is just a wide spot in the corridor and does not have to meet the requirements for areas open to the corridor in sections 18/19.3.6.1. But, I’m not the AHJ, and they never ask me what I think anyway.

 

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Aug 15 2013

New Construction Corridor Doors

Category: BlogBKeyes @ 5:00 am
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door_thickness[1]I was recently asked what the Life Safety Code required for the thickness and composition of a corridor door in new healthcare occupancy construction. The individual asking me the question was thinking of installing 3/4 inch thick doors on nurse server cabinets which open onto the corridor. I recited from memory: 1.75 inch thick, solid-bonded, wood core doors that limit the passage of smoke and have positive latching hardware. There are some basics in life that cause one to memorize such things and corridor doors is just one of those items in the Life Safety Code for me.

The person asking the question asked me to provide the code reference where it says that. So, I looked it up in Chapter 18 (the chapter for new construction in healthcare occupancies) and …. it’s not there. The code is void of that description for corridor doors in the new construction chapter. Section 18.3.6.3.1 (of the 2000 edition) of the Life Safety Code essentially says corridors doors have to limit the passage of smoke, and they do not have to comply with NFPA 80 , and the distance between the bottom of the door and the floor cannot exceed 1 inch. Also, section 18.3.6.3.2 says corridor doors are required to positively latch, and roller latches are not permitted. Nowhere in Chapter 18 can I find that the corridor door had to be constructed to be 1.75 inch thick, solid-bonded and wood core. I even pulled out the handbook for the LSC and it was silent on the subject for new construction. I looked up the same section in the 2012 edition of the LSC to see what it says and it too was very silent as well.

So why was I so quick in quoting corridors doors need to be 1.75 inch thick, solid-bonded wood core? Because that is the requirement for corridor doors in existing construction. Oh… Now it makes sense. One needs to remember that section 4.6.7 says in part, that alterations and new equipment needs to comply with new occupancy chapters, and at the very least must meet the requirements for existing conditions. So, I said they cannot install a new corridor door that does not meet the requirements for an existing corridor door, which is 1.75 inch thick, solid-bonded, wood core.

I was asked where in the code it says that and I referred him to section 19.3.6.3.1. I then read the Exception #2 to 19.3.6.3.1 which says corridor doors in smoke compartment fully protected with automatic sprinklers are exempt from this requirement, although they are required to be constructed to resist the passage of smoke…. Oops!…. There’s the hidden truth. Corridor doors in existing occupancies located in smoke compartments that are fully protected with sprinklers are not required to be 1.75 inch thick, yada yada yada.

Corridor doors in new construction are located in smoke compartments that are fully protected with sprinklers, so by the definition of section 4.6.7, a 3/4 inch thick door on a nurse server cabinet that opens onto the corridor would be permitted in new construction, as long as it resists the transfer of smoke and positively latches.

Wow… I learned something new that day. It never ceases to amaze me to learn of the little nuances and intricacies involved in understanding the Life Safety Code. That was a good day for me. I really appreciated that question as it made me learn the truth.

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Apr 13 2012

Corridor Alcoves

Category: BlogBKeyes @ 5:00 am
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In regards to corridor clutter, one of the most frequent comments safety professionals hear from nurses and other point-of-care workers, is “I have no place to put the ____” and you can fill in the blank with just about anything. The sad thing is, this is true more often than not. Nurses like to have ‘things’ close by and near their patients, for quick access, and it’s not their fault there simply isn’t suitable space to store them.

Now, I can imagine some of you may be saying, “But Brad, those nurses keep leaving things in the corridor even after I’ve told them that they can’t do that”, which may very well be true. But you have to ask yourself, ‘Why are they doing that?’ Why do nurses want ‘stuff’ in the corridor even when they’ve been told not to? Before I can even get that last sentence out, I know some will say it’s because the nurses are lazy and they don’t want to walk the extra 30 – 50 feet to the storage room. Well, that may be true, but you may be surprised how often that is not the case.

Nurses are some of the best trained people in the hospital. If it weren’t for nurses, none of us would have a job in healthcare. The hospital exists to provide care for the patients and the nurses are the ones who do that the best. Nurses have the patient’s best interests at heart, and everything they do is geared towards providing excellent care for their patient. Many nurses believe by having certain medical equipment, such as blood pressure cuff machines, EKG machines, IV pumps, and the like, accessible and close by the patient’s room, they are providing the best care possible for the patient. In their minds, keeping those items in the storage room 30 – 50 feet down the corridor would only delay the ability to provide excellent care, so they need that stuff in the corridor, just outside the patient room.

Once the facility managers accept this concept, now they can begin thinking like the nurses, and try and find ways to help them have these items nearby. One solution is the creation of alcoves in the corridor, just like the one in the picture. Here’s how one hospital accomplished this…

First, they found a former patient room on the nursing unit that was being used to store items, including large items such as beds, patient lifts and extra mattresses. Inside this former patient room was a bathroom which was not used and only taking up valuable space. So, the facility manager decided to tear out the bathroom and pushed back the corridor wall that contained the entrance door to the room, about 5 feet. He rebuilt the wall separating the corridor from the storage room, which left him with a very nice alcove for the items that nurses used most often. By tearing out the bathroom, the hospital had to re-route plumbing and electric lines, and fix the floor, but the end result was very beneficial for the nurses. And this actually created more storage space since the unused bathroom was eliminated. Now the nurses can store equipment in the alcove, without having to open the door and place it in the storage room. This is a big advantage for those items that nurses want quick access to.

This ‘after-the-fact’ process of creating alcoves in the corridor is not cheap. The one in the picture cost around $15,000 or so, but if your administration is serious about solving corridor clutter in your organization, they should be able to provide the funds. I suggest you seriously consider this approach… It is a great satisfier for the nurses and you’ll make friends for the rest of your career.

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Mar 30 2012

Locked Doors to Utility Rooms?

Category: BlogBKeyes @ 3:37 pm
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Utility rooms, whether they are clean utility rooms, or soiled utility rooms, are not required to be locked according to any NFPA standard, Joint Commission standard or CMS Condition or standard. However, if there is a perceived risk to safety because a utility room door is left unlocked and the hospital has failed to assess that risk, then the surveyor or inspector has every right to cite the organization for ‘interior spaces which are unsafe to occupants of the building’. This would be scored under EC.02.06.01, EP 1 for Joint Commission, or under §482.41 for CMS. The big problem with §482.41 for CMS is this is a ‘Condition’ rather than a standard that would be considered out of compliance and that alone would trigger a full-fledged CMS validation survey, which is very undesirable.  So this is something you definitely do not want to happen at a hospital.

So, the way a risk assessment is conducted to determine if a perceived risk is OK as is, or if something further needs to be done to compensate for that risk, is very simple. Take a sheet of paper, draw a vertical line down the middle, and list all the ‘Pros’ of the risk on the left side and all the ‘Cons’ of the risk on the right side. Whichever side has the most items or the most severe items listed, wins. If the ‘Pro’ side wins, then you don’t have to lock the door, but if the ‘Con’ side wins, then the doors should be locked.

Here’s an easy example: For a pediatric unit, where it is not uncommon to see children patients walking up and down the corridor (even though they are supervised) a clean or soiled utility room door which is not locked poses a HUGE risk to safety for the children, and the utility room doors should be locked. However, utility room doors on a geriatric unit does not pose the same risk as there are far fewer children roaming the hallways, so the doors could remain unlocked.

The risk assessment has to be documented, and I always advise my clients to have many stakeholders involved in the risk assessment process, including:

  • Safety officer
  • Security manager
  • Facility manager
  • Infection Control manager
  • Nurse manager
  • Chief Nurse Executive
  • Risk manager
  • Etc.

Then, once the risk assessment is complete, I advise them to have it reviewed and approved by the Safety Committee, and get it in the minutes. Then, if ever challenged by a surveyor or inspector who thinks the doors should be locked, you can tell them:

  • There is no code or standard that requires the doors to be locked
  • An assessment to determine the level of risk to the patients was conducted by an interdisciplinary team of professionals who decided that the doors are not required to be locked (or are required to be locked, depending on the outcome of the risk assessment)
  • This risk assessment decision was affirmed by the organization’s Safety Committee and here are the minutes to indicate that

The risk assessment process is a great tool to use when decisive action is not clear, or when the codes and standards do not seem to address an issue very well. You can never go wrong with a risk assessment especially if many different professionals (who have the best interests for the safety of the patient at heart) agree on the conclusion.

One last thing… Risk assessments are not ‘forever’. They should be renewed once a year to see if any of the conditions have changed.

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