Mar 30 2012

Locked Doors to Utility Rooms?

Category: BlogBKeyes @ 3:37 pm

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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Feb 24 2012

Door Locks for Safety Needs

Category: Life Safety Code UpdateBKeyes @ 6:00 am

As we discussed in the previous posting, the healthcare chapters of the Life Safety Code allows for three (3) special locking arrangements:

  1. Clincal needs
  2. Delayed egress
  3. Access control

The phrase ‘Clinical needs’ was always poorly defined (or not defined at all) in the 2000 edition of the LSC, and was left to the authority having jurisdiction (AHJ) to decide for themselves what doors in a hospital qualify for locking arrangement as allowed by ‘clinical needs’. Many AHJs were liberal and allowed ‘clinical needs’ locks not only for psychiatric or Alzheimer’s patients, but also for infant security as well. However, there are some state AHJs who represent CMS that did not permit the use of ‘clinical needs’ locks for infant security. That alone caused quite a bit of problems for hospital facility managers.

Well, the 2012 edition includes explanatory information (which is not in the 2000 edition) in the annex section that identifies psychiatric, Alzheimer’s and dementia patients as examples where ‘clinical needs’ locks would be allowed. It specifically did not include infant security protection. However, section of the 2012 edition says:

“Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met:

  • Staff can readily unlock doors at all times
  • A total (complete) smoke detection system is provided throughout the locked space or locked doors can be remotely unlocked at an approved, constantly attended lcoation within the locked space
  • The building is protected throughout by an approved, supervised automatic sprinkler system
  • The locaks are electrical locks that fail safely so as to release upon loss of power to the device
  • The locks release by independent activation of a smoke detection system or waterflow in the automatic sprinkler system”

The Annex section of does state pediatric units, maternity units and emergency departments as examples that qualify foir ‘safety needs’ locks. Now, the Annex section is not part of the enforcable code, but it does offer guidance and direction for AHJs to follow on their over-all interpretation of the the LSC. This new section in the 2012 edition should solve the debate if a nursery or pediatric unit can be locked.


Feb 22 2012

Changes With Electrically Locked Doors

Category: Life Safety Code UpdateBKeyes @ 6:00 am

Electrically locked doors. The 2000 edition of the LSC does not discuss them, directly. However, it does talk about the three types of locks that are permitted in hospitals: 1). Clinical needs; 2). Delayed egress, and 3). Access control.

Access control locks are the most misunderstood locks in hospitals today, and I would say nearly all the hospitals that I visit, have some sort of deficiency with access control locks. Let’s review quickly what is required for access control locks: A motion sensor on the egress side; A wall-mounted ‘Push to Exit’ button within 5 feet of the door; When the ‘Push to Exit’ button is depressed, it interrupts power to the lock for a minimum of 30 seconds; A loss of power to the control system renders the lock disabled; And activation of the building’s fire alarm or sprinkler system automatically unlocks the door. Nearly all of the access control locks that I have seen in my career utilize magnetic door locks, or mag-locks for short. These access control locks end up being a problem for facility managers because they get installed by well-intentioned, but poorly informed individuals who do not consult with the person who is knowledgeable on the Life Safety Code.

Now, when the 2012 edition of the LSC is adopted, there will be a new version of door locks, that will solve a lot of these problems. The three locks permitted in hospitals (clinical needs, delayed egress, and access control) will remain, but Chapter 7 will now permit doors that are ‘electrically locked’ to be considered the same as any other normal lock on the door. Section says:

“Door assemblies in  the means of egress shall be permitted to be electrically locked if equipped with approved, listed hardware, provided that all of the following conditions are met:

  • The hardware for the occupant release of the lock is affixed to the door leaf
  • The operation has an obvious method of operation that is readily operated in the direction of egress
  • The hardware is capable of being operated with one hand in the direction of egress
  • Operation of the hardware interrupts the power supply directly to the electric lock and unlocks the door assembly in the direction of egress
  • Loss of power to the listed releasing hardware automatically unlocks the door assembly in the direction of egress
  • Hardware for new installation is listed in accordance with ANSI/UL 294.”

Now it is important to note that this section is under the heading of “Locks, Latches and Alarm Devices” (2012 edition) and is not under the the heading “Special Locking Arrangements”. That implies this new ‘electrically locked door’ section is not considered a special locking arrangement, but places it squarely on the same level as regular door locks. This is significant, as the healthcare chapter (18 and 19) specifically permits this new ‘electrically locked door’ under section 18/, which says “Doors complying with 7.2.1 shall be permitted.” Well, that alone permits and does not require it to qualify as a ‘Special Locking Arrangement’ in, which includes the access control requirements.

So, the mag-lock in the picture below is the typical ‘electrically controlled lock’ used in hospitals, and when the 2012 edition is finally adopted, this lock will be allowed (in accordance with the provisions of in lieu of access control locks. However, be careful with the application and selection of equipment. The electronic ‘touch-sensitive’ crash bar in the picture above, probably would not be permitted, as a person wearing a glove would not be able to make the completion of the electrical circuit that bare skin requires. Also, those applications where a card-swipe reader or a proximity reader is used in conjunction with a mag-lock will not qualify for the ‘electrically controlled locks’, as those locks require the use of a special tool. Section (2012 edition) still does not allow the use of a special key or tool to operate the lock.



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