Keys to Unlock Doors

Q: We have a Geri-Psych unit and the stairwells are locked on that unit. Back in 2009, you surveyed our facility and wrote in your findings, “The housekeeper person on the Geri-Psych unit does not have a key on her person to unlock the exit doors.” This is a battle that we are continually fighting. We need some ammunition! Can you please provide me with the code that would require them to have keys on their person (since common sense isn’t so common around here)?

A: Look at section of the 2012 LSC. It says staff can readily unlock the doors at all times. Housekeepers, maintenance, food service, physicians, nurses, therapists, etc., are all ‘staff’, and each one working inside the locked unit needs to be able to unlock the doors. Therefore, each staff member must have a key or device to unlock the doors on their person.

Fire Drills in the Behavioral Health Unit

Q: I work at a hospital that has just partnered with a Behavioral Health organization. We have renovated a floor and will be opening up soon. My question is this: For fire drills in the main hospital, I am sure it would be best to separate these activities from the Behavioral Health unit. And I am sure we would need to be notified on our panel if an event happened on the unit. Am I on the right track? Is there any code that speaks to this? In addition, what would be your suggestions in regard to stairwell egress in the case of an alarm on the Behavioral Health unit. Delayed egress? Clinical needs locks?

 A: Okay… so there is a lot to cover here. As I understand your question, you will soon be opening a behavioral health unit in an existing acute-care hospital. You say you are partnering with another organization… does this mean the behavioral health unit is a separate entity (i.e. does it have a separate CMS certification number) from the acute-care hospital?

 If the behavioral health unit is a separate entity, then you must conduct separate fire drills (once per shift per quarter) in the behavioral health unit as compared to the rest of the acute-care hospital. If the behavioral health unit is not a separate entity, then you are not required to conduct separate fire drills from the rest of the acute-care hospital. So, you need to verify if the behavioral health unit will be a separate entity from the acute-care hospital.  

The fire alarm control system is a system for the entire building, even if there are separate entities inside the building. If a fire alarm originated on the behavioral health unit, you most definitely need to know about it in the acute-care hospital, and vice-versa.

The behavioral health unit would likely qualify for clinical needs locks as described in of the 2012 LSC. These locks are not required to automatically unlock on activation of the fire alarm system. You can do that if you want, but there is no requirement to do so. Actually, you really don’t want the locks on the doors in the behavioral health unit to automatically unlock on a fire alarm, because patients will soon figure that out and will loiter around the locked egress doors and jump at the chance to elope whenever a fire alarm actuates. I do not suggest delayed egress locks, but rather clinical needs locks as long as you qualify for them.  

Strange Observations – Part 43

Continuing in a series of strange things that I have seen while consulting at hospitals…


Where do you see public pay-phones in a hospital, anymore….?

In the behavioral health unit, that’s where. Or at least, that is where I saw this one.

The problem here is the phone and the wood booth projects more than 4-inches into the corridor, which is the maximum allowable amount by CMS.

Another problem that many of you readers pointed out that I forgot to mention, is the long cord on the telephone is a ligature risk.

Blood Draw in Behavioral Health Corridor

Q: I have a behavioral health unit where the lab technicians have placed a chair in the corridor to draw blood samples from the patients. This chair is left in the corridor at all times, and the corridor is 8 feet wide. Is this a violation and do I need to maintain 8 feet clear width in this corridor?

A: Yes… I believe it is a problem, but not for the reasons you imply.

Section of the 2012 LSC says corridors in psychiatric hospitals are required to have unobstructed clear width of 6 feet; not the traditional 8 feet clear width required in acute care hospitals. So, a chair placed in an 8 foot wide corridor in a psychiatric unit would likely not obstruct the required clear width of 6 feet. However, take a look at section This section sates that corridors must be separated from all other areas of the hospital with partitions. Now, there are 9 exceptions where corridors are not required to be separated from certain areas of the hospital, but none of these exceptions allow areas used for patient sleeping rooms, treatment rooms or hazardous spaces to be open to the corridor.

The question here is; what constitutes a ‘patient treatment room’? Does a chair that is legally placed in the corridor for patient blood draw constitute a patient treatment room or space? Maybe yes, and maybe no. Being an engineer, I cannot make that decision. I suggest you have your clinical staff perform a risk assessment and review the procedures that are being done at this location to determine if it meets the qualifications for ‘patient treatment’. If the results of the risk assessment state that blood draw is not ‘patient treatment’ activities, then have them take the results of that risk assessment to the safety committee and the patient safety committee (if they are not one and the same) and have those committees review and approve the results.

If a surveyor challenges you that the blood draw constitutes ‘patient treatment’ activities open to a corridor, then present the risk assessment. While this is not a guarantee that the surveyor will accept the results of the risk assessment, it will demonstrate to the surveyor that you are aware of this issue and conducted an evaluation and determined it is not ‘patient treatment’ activities.