Card Readers on Door Locks

Q: During a recent survey, the surveyor said a card reader on the stairwell door cannot be located on an adjacent wall or door frame, but it must be an integral part of the lockset itself. Is this true? They were talking about card readers on the stairwell side for re-entry to a floor.

A: Did the surveyor cite you for non-compliance? If not, surveyors sometimes say things that are misunderstood, especially if there is no citation. Doors not in the path of egress are permitted to be locked, and a re-entry door from a stairwell usually is not in the path of egress. As long as the re-entry door in the stairwell is not in the path of egress then I do not see any reason that what you describe would be a problem. The Life Safety Code would allow for a card reader device to unlock a stairwell re-entry door as long as the door is not in the path of egress.  If the card reader is mounted in the stairwell on the door leading to a floor of the building (not a discharge door), then the card reader is not on the egress side of the door. There is nothing in the Life Safety Code, or in NFPA 80 Standard for Fire Doors and Fire Windows, (1999 edition) that would require the card reader to be mounted on the door leaf, rather than the on the wall near the door. Therefore, it is clear that the LSC permits card-access readers to be mounted on the wall near the door, since it is not a device or motion to operate the door. I cannot think of any situation that would require the card-access reader to be mounted on the door leaf, itself.

Locked Doors for Utility Rooms?

Q: Where is the reference in the Life Safety Code that requires the doors to housekeeping or soiled utility rooms to be locked? I have a Risk Management director that tells me the code requires these doors to be locked.

A: There is no Life Safety Code requirement to lock housekeeping or soiled utility room doors. There is no Joint Commission, CMS or any other national authority that requires housekeeping or soiled utility room doors to be locked. Where hospitals get into trouble with CMS and the accreditation organizations on this issue is the failure to assess the risk to safety for patients and staff, when these doors are left unlocked. Each of the national authorities has a standard that requires hospitals to either identify safety and security risks in the environment, or their standard requires the hospital to maintain a safe environment for their patients.  An unlocked utility room that contains a risk to the patients would certainly be suspicious to a surveyor that the environment may not be safe for the patients. A housekeeping room may contain cleaning supplies that could be considered dangerous to unauthorized individuals (such as children). If the door to the housekeeping room was left unlocked, then people could gain access to the hazardous items and hurt themselves or others. Likewise for soiled utility rooms, which by definition would have soiled linens which may be bio-hazardous. This does not mean all soiled utility rooms or housekeeping rooms need to be locked. They just have to be assessed for the safety or security risks associated with the contents of the rooms. In my encounters, most of the soiled utility rooms that I see in hospitals are unlocked. Only soiled utility rooms where children are prevalent are the ones that are typically locked. Now, on the other hand, most (if not all) housekeeping janitor’s closets that I see are locked, partly due to the hazardous cleaning chemicals stored in them, but also because Housekeeping doesn’t want their other supplies stolen. But, to be sure, there is no direct requirement in the LSC or in the accreditation organization standards to keep these doors locked.

Delayed Egress on Doors in Ambulatory Health Care Occupancies


A friend of mine was working on a project involving ambulatory health care occupancy, and they wanted to use a delayed egress lock on an interior door.  The 2000 Life Safety Code (LSC) limits special locking arrangements to exterior doors in ambulatory health care occupancy, but the 2012 LSC does not include that limitation.  They wanted to know what I would recommend.

Well, they are correct: The 2012 edition of the LSC did away with the limitations of the special locking arrangements found in section of the LSC. Section 20/ of the 2012 edition of the LSC now permits delayed egress locks on any door in the path of egress, where the 2000 edition of the LSC limited them to the exterior door.

I assumed that the individual who asked me the question was bound by the 2000 edition of the LSC, such as a Joint Commission accredited organization, or perhaps a CMS provider for Medicare. My initial thought is the organization would have to comply with the conditions of the 2000 edition of the LSC, and cannot take advantage of the more lenient 2012 edition until such time that edition is adopted by CMS and/or Joint Commission.

However, CMS did issue a categorical waiver to healthcare organizations to allow them to use many of the provisions of the 2012 edition of the LSC now, before the 2012 edition is actually adopted (which may be at least another 12 months away). I reviewed the CMS S&C memo 13-58 once again, and while CMS did state in one of their opening paragraphs that they have the authority to grant waivers for ambulatory surgical centers, they failed to do so in the body of their memo. They have a categorical waiver on doors to allow healthcare occupancies to use the more liberal 2012 LSC position on delayed egress locks, but that categorical waiver only applies to healthcare occupancies, and not ambulatory surgical centers, assuming the ambulatory health care occupancy my friend was referring to was an ambulatory surgical center.

Therefore, I concluded that the organization should (or must) comply with the 2000 edition of the LSC and only install special locking arrangements on exterior doors. Once the 2012 edition of the LSC is adopted, they can then install delayed egress locks on interior doors.

I also mentioned that if the facility in question is only accredited by The Joint Commission, and does not receive any funds from CMS as a Medicare or Medicaid provider, then they could contact the Standards Interpretation Group (SIG) at Joint Commission and ask them if they would accept a Traditional Equivalency to allow them to use special locking arrangements on interior doors of their ambulatory care occupancy. (The telephone number for SIG is:  630-792-5900, select option 6.) My guess is they will, provided the organization meets all the requirements for a traditional equivalency.

If the facility in question actually is part of a larger organization that does have a CMS control number (CCN), then I advised my friend that they have no choice by to comply with the conditions of the 2000 edition of the LSC.

My friend replied asking if they could request a standard CMS waiver to allow the organization to install the delayed egress lock on an interior door now, before the 2012 edition of the LSC is adopted.

My reply was yes, there is always the possibility for a waiver, but CMS will not accept a waiver request unless it is in response to a survey deficiency. In other words, the waiver process is not valid until someone representing CMS cites a deficiency.

As a safety professional, I would never recommend or advise a client to knowingly violate the current edition of the LSC, even though we know that issue will be viewed differently in a more recent edition. There is always the chance that CMS may not adopt the 2012 LSC, although I would be very surprised if they did not.

However, any organization may do what they want, and often times they disregard the advice of a safety professional, and violate the LSC, taking the risk that they will not get caught. In this case, it is understandable as the presumption is the 2012 edition will be effective within the next 12 months or so, and they may feel they will not have any surveys or inspections before then.

So… in summary: The waiver process is not available to them since they have not been cited for non-compliance with the LSC. And, as a safety professional I cannot advise them to violate the LSC. What they do after that is their own business, and risk.

I have some clients who ignore my advice, preferring to ask other safety experts until they find someone who agrees with the answer they want. Hey… it’s their hospital, not mine. I always advise clients to follow the current rules, regulations, codes and standards, but if they decide otherwise, then that’s on them.

Locks vs Latches

Q: A surveyor cited us for not having positive latching doors to our entrance of the ICU suite. We have magnetic-locks on those doors and pointed out that they serve as positive latching. He refused our position and cited us anyway. Don’t magnetic locks qualify as positive latching hardware on doors?

A: No, they do not. Locks are not the same as positive latches. The magnetic locks that you mentioned are most likely access-control locks as described in section of the 2000 edition of the Life Safety Code. Those electronic magnetic locks are required to unlock upon activation of the fire alarm system. That’s when you need the corridor door to positively latch the most: during a fire. Also, make sure there is a motion sensor mounted on the egress side of the doors served by the magnetic locks, along with a button mounted on the wall within 5 feet of the doors, when activated will unlock the magnetic-locks for a minimum of 30 seconds. The button must be labeled “Push to Exit”.

More on Dead-Bolt Locks

Dead-bolt lock on door Web 2If you search my website on door locks, you will find a few entries concerning dead-bolt locks. For decades hospitals seem to have installed dead-bolt locks on any door they wanted, without any concern for compliance with the Life Safety Code. That’s all changing now, as surveyors and inspectors are becoming better educated on where dead-bolt locks may be used.

The picture to the left shows a dead-bolt lock on a corridor door that is separated from and is not part of the latch-set. It is mounted approximately 12 inches above the latch-set handle and in order to egress through this door, an individual would have to make two releasing motions: 1). unlock the dead-bolt, and 2). turn the latch-set handle. Those two actions make this dead-bolt installation non-compliant with section of the 2000 edition of the LSC, which prohibits more than one releasing actions to operate the door.

Some people are quick to point out that dead-bolt locks installed as described above are approved for use on patient room doors in psychiatric units where ‘clinical needs’ locks are permitted. My reply would be, approved by who?  I am aware that Joint Commission has made an interpretation that permits their accredited organizations to have dead-bolt locks on psychiatric units, but that does not address the improper installation of them. Just because Joint Commission says you can have dead-bolt locks, does not mean you are permitted to install them incorrectly.

Hotel Door Latch & Lock Web 2The picture to the left shows a dead-bolt lock that is integrated (not separated) with the latch-set. This arrangement allows the retraction of the dead-bolt simply by turning the latch-set handle, and thereby complying with section with a single releasing motion to operate the door. [NOTE: NFPA Healthcare Interpretations Task Force has ruled that pulling or pushing is not considered a motion to operate the door.]

This would be an excellent solution for those situations where you wanted to have a dead-bolt lock installed on a door in the path of egress. This concept of latch-set & dead-bolt lock combined could be obtained in anti-ligature arrangement, and be used in a psychiatric unit.

But there are situations where a traditional dead-bolt lock could be used on a door in the path of egress in a healthcare occupancy. Where? How about in areas where the corridor door is not required to latch?

There are multiple locations in a hospital where doors that open onto a corridor are not required to latch: bathrooms, toilet rooms, shower rooms, and sink rooms that do not contain any combustibles. Also, how about the exterior doors in a Type I or Type II building? Those doors aren’t required to be fire rated, so there is no requirement for exterior doors to latch, either. [Now, most hospitals want their exterior doors to latch even if they aren’t required to, in order to keep the weather and the riff-raff out, but in some rare situations such as the main entrance consisting of sliding glass doors, latching may not be desired.]

Dead-bolt lock on corridor door Web 2The picture to the left shows a door with a dead-bolt lock, but there is no other releasing device mounted on this door, such as a latch-set. While this door would not be permitted in many locations in a hospital corridor because it does not latch, it would be permitted on doors to rooms that are not required to latch, according to (toilet rooms, bathrooms, shower rooms, and sink closet not containing combustibles). So a door in the path of egress with a dead-bolt lock and no latch-set on one of these limited rooms would still be compliant with section because there is only one releasing action to operate the door: turning the thumb-screw to unlock the door.

Dead-bolt locks that are installed on corridor doors that are required to latch in such a way that they are separated from the latch-set, are just big red flags to surveyors and inspectors. If the door requires two releasing actions to operate the door, then that’s a violation, and they are easy to find. Check out your facility… it may be possible that you have a deficiency that you are not aware.

Door Locks in Healthcare Occupancies

exit_mag_lock_hospital_10662932[1]Outside of the healthcare setting, locks on doors are utilized nearly everywhere we go, and we don’t give it much of a thought. But in the highly regulated industry of healthcare, we must be very vigilant and astute to what the codes and standards will and will not permit. Unfortunately, locks on doors that are in the path of egress are greatly misunderstood by hospitals, and therefore are widely abused.

 Ordinarily, you are not permitted to lock a door in the path of egress in a healthcare occupancy however, there are three exceptions:

  • Delayed egress locks
  • Access-control locks
  • Clinical needs locks

 Delayed Egress

Delayed egress locks are a lock when a person pushes on the horizontal crash bar of the locked door, a local buzzer will sound, and the door will automatically unlock within 15 seconds. This effectively allows a person to egress through the door, but just delays their egress, hence the name. The requirements for a delayed egress lock are:

  • Delayed egress locks are only permitted in buildings which are fully protected with smoke detectors or automatic sprinklers
  • The delayed egress locks must unlock upon activation of the sprinkler system or a heat detector or a smoke detector, and remain unlocked until manually reset. Notice that activation of a manual pull station is not required to unlock a delayed egress lock.
  • The delayed egress locks must unlock upon loss of power to the mechanism controlling the lock
  • Upon 3 seconds of activating the releasing device (horizontal crash bar) a local buzzer must actuate (to alert staff someone is attempting to exit), and within 15 seconds of activating the releasing device, the lock shall automatically unlock. The locks must reset manually, not automatically.
  • The code allows for the delayed egress lock to automatically unlock within 30 seconds if approved by the AHJ, but HFAP does not approve of this option.
  • A sign, in 1 inch letters, must be posted on the door which reads:



  • Only one delayed egress lock may be installed in the path of egress to the public way.

These types of locks are not uncommon in hospitals, but are not used very much. The most common deficiency observed with delayed egress locks is they are installed in a building that is not 100% protected with sprinklers or smoke detectors. [Code reference:, 2000 edition of the LSC]

 Access Control

Access Control locks are very common in hospitals, and most likely are misunderstood on their correct operation by the facilities staff.  An access control lock usually utilizes a magnetic lock (mag-lock) assembly, and is often integrated with the badge swipe reader to control access into a department. The requirements for an access control lock, are:

  • A motion senor must be mounted on the egress side of the door, that will detect a person approaching and will automatically unlock the door in the direction of egress
  • A loss of power to the device controlling power to the access control lock must unlock the doors in the direction of egress
  • A manual release device must be mounted within 5 feet of the door, and between 40 to 48 inches above the floor which, when depressed, will automatically unlock the door in the direction of egress, and must be identified with a  sign that reads:


  • When depressed, the “Push to Exit” button must directly interrupt power to the lock, independent of the access control system electronics, and the doors must remain unlocked for a minimum of 30 seconds
  • Activation of the building sprinkler system or the building fire alarm system must unlock the door in the direction of egress

The most common deficiency with access control locks is the absence of the required motion sensor and/or the “Push to Exit’ button on the egress side of the door. When properly installed, access control locks are not a lock for people trying to get out of the building, but they serve as a lock on doors for people trying to get into the area controlled by the lock. [Code reference:, 2000 edition of the LSC]

 Clinical Needs

Clinical needs locks are only permitted in healthcare occupancies (hospitals). They are not permitted in any other occupancy. These types of locks are permitted where the “clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times”. Clinical needs locks are permitted for Behavioral Health units, such as psychiatric and Alzheimer units, to prevent patients from leaving the unit unauthorized, and potentially harming themselves or others.  Clinical needs locks requires all staff who work on that unit (which includes physicians, nurses, aids, clerical, maintenance, foodservice, housekeeping, etc.) to have a key or device to unlock the door on their person at all times. [Code reference:, Exception No. 1, 2000 edition of the LSC]

 Fire Alarm Connection

Delayed egress locks and access control locks are required by code to be connected to the fire alarm system and automatically unlock the door whenever there is an alarm. However, there is no such similar language for clinical needs locks to unlock on an alarm. In addition to the Life Safety Code, NFPA 72 National Fire Alarm Code, (1999 edition) section 3-9.7.1 and 3-9.7.2 says if you have a lock on an exit door it must be connected to the fire alarm system, and it must unlock the door on a fire alarm. HOWEVER, the exception to 3-9.7.2 essentially says this is not required if an AHJ says so, or if another code says so. So, we go back to the Life Safety Code, and we see that delayed egress locks and access control locks are required to unlock on an alarm, but the clinical needs locks is very silent on the subject. When a code is silent on a subject that means it permits it.  Therefore, section 3-9.7 does not apply to clinical needs locks in a hospital, because the Life Safety Code permits it. The code writers understand that psych patients are smart enough to actuate a fire alarm to unlock the exit doors. Therefore, they wrote the code in such a way to not require clinical needs locks to unlock the doors in the path of egress on activation of the fire alarm system PROVIDED all staff carry a key to unlock the door in case of an emergency. That is the trade-off: They will not require the locks to unlock on a fire alarm, as long as all staff can unlock the doors in the event of an emergency.

 Dead Bolt Locks

Generally speaking, dead bolt locks are not permitted on a door in the path of egress in a healthcare occupancy. The only exception would be a dead bolt lock which automatically retracts when the door handle is twisted but other than that, they are not allowed. The reason for this is the LSC only permits one releasing action to operate the door. So if a dead bolt lock is installed on a door in the path of egress and the lock is not part of the latch-set, then it would require two actions: one to unlock the dead bolt and another to turn the door handle, to operate the door. Please note that pulling or pushing is not considered one of the actions to operate the door. [Code reference:, 2000 edition of the LSC]


Dead-Bolt Locks on Psychiatric Rooms

Q: In a Psychiatric hospital emergency room, are patient holding rooms allowed to have dead bolts on the corridor side with no thumb latch on the inside of the room? Our Administrator’s position is that those rooms can be used as seclusion rooms at any given time. Is that acceptable?

A: Interesting question. I would say it depends if the seclusion room would only be used for the purpose of securing individuals who present a threat to themselves or others. This is commonly called “clinical needs” and is allowed under section, exception number 1 of the 2000 edition of the LSC. However, if the same room is used for a non-behavioral health patient then the locks would not be permitted. Section does not allow more than one action to operate the door in the path of egress, and a dead-bolt and a door latch would be more than one operation. Can you guarantee this room would never be used for seclusion? If not, then I would think most authorities would have a problem with it. This is going to end up as an interpretation from an authority having jurisdiction (AHJ). The average hospital has 5 or more AHJs and even if 4 AHJs don’t have a problem with the dead-bolt locks, and the 5th AHJ does, then you have to comply, and remove the dead-bolt locks. Most hospitals deal with this issue by having sitters watch the patient. Not the best solution, but it does meet the code requirements.

Testing Delayed Egress Hardware

NOTE:  My good friend Lori Greene from Ingersoll Rand Security Technologies had this comment posted on her website /blog:  last August 15th, addressing the testing requirements for delayed egress locks. I know some of you readers are already subscribers of Lori’s blog and probably have already read this comment. But I thought this was such a well-researched answer by Lori, that those individuals who are not yet regular readers of ‘I Dig Hardware’ might benefit from her knowledge. It is a very relevant subject to the healthcare setting, so with Lori’s permission, I am repeating her answer to the question: “What are the testing requirements for delayed egress locks?”   Brad Keyes


Testing Delayed Egress Hardware- What are the Requirements?

( by Lori Greene)

The 2009 International Building Code (IBC) doesn’t include testing guidelines in section 1008.1.9.7 Delayed Egress Locks, but that makes sense because the IBC is used during construction and not for ongoing maintenance.  I checked the 2009 International Fire Code, and the section for delayed egress locks is exactly the same as the one in the IBC.  But since a delayed egress lock requires immediate release upon fire alarm, I thought I might find something in Chapter 9 of the IFC – Fire Protection Systems.  In the section on Testing, Inspection, and Maintenance (907.9), I found this statement:  “Testing. Testing shall be performed in accordance with the schedules in NFPA 72 or more frequently where required by the fire code official.”

NFPA 72 is the National Fire Alarm and Signaling Code.  There were some changes in the 2010 edition relative to this question, so I used that edition in my research.  According to NFPA 72-2010, “door unlocking” falls into the category of “emergency control functions”:  “Emergency control functions (i.e., fan control, smoke damper operation, elevator recall, elevator power shutdown, door holder release, shutter release, door unlocking, etc.) shall be tested by operating or simulating alarm signals. Testing frequency for emergency control functions shall be the same as the frequency required for the initiating device that activates the emergency control function.”  (Table

Here’s some related information from Annex A – Explanatory Material:

Table, Item 23. Initiating devices configured to operate an emergency control function are required to be tested per the test methods listed in Table, Item 14 and the test frequencies listed in Table 14.4.5, Item 15. Whenever an emergency control function is observed to not operate properly during a test of an emergency control function initiating device, the problem should be reported to the building owner or designated representative. The failure of the emergency control function should be reported as a possible failure of the fire safety feature and not necessarily of the fire alarm system.

Here’s what NFPA 72-2010 says in the inspection/testing section about emergency control functions:

14.2.6 Interface Equipment and Emergency Control Functions.* Testing personnel shall be qualified and experienced in the arrangement and operation of interface equipment and emergency control functions. Testing shall be accomplished in accordance with Table

And finally, Table 14.4.5 says that emergency control functions must be tested annually, as well as upon acceptance/reacceptance.  So a delayed egress lock must be tested when it is installed, repaired, or replaced, and then annually after that.  Since NFPA 72 deals with fire alarm systems, the testing requirement is probably more related to whether the fire alarm unlocks the doors, but I think it makes sense to test the 15-second release at least annually too.  I don’t know of a specific requirement for testing that part of the delayed egress lock, other than the NFPA 101 – Life Safety Code requirement for certain egress doors to be inspected annually, depending on the occupancy type.  Local jurisdictions may require more frequent testing / inspection, and facilities may choose to increase the required frequency of testing and establish a specific process to ensure the safety of building occupants


From a healthcare facility point of view, I think Lori nailed the issue straight on top of the head. I agree 100% with what she said and would not have anything to add to your code search.

My experience tells me that currently, few Joint Commission surveyors or CMS inspectors actually request to see documentation on testing delayed egress locks, although it is clear the 1999 edition of NFPA 72 requires testing all interface devices connected to the fire alarm control panel. In order for a delayed egress to operate correctly, it must have an interface device between the delayed egress locks and the fire alarm control panel.

I believe surveyor and inspector awareness will improve when the CMS finally adopts the 2012 edition of the LSC, as the 2010 NFPA 72 explains the testing of emergency control functions much better.

Thank you Lori, for a well thought-out answer.      Brad Keyes


Application of Delayed Egress Locks and Access Control Locks

I was recently asked to explain the difference between delayed egress (DE) locks and access controll (ACE) locks, and what are their applications.

The main difference between DE and ACE locks is, DE locks provide a measure of security in the path of egress, where ACE locks do not. The DE lock provides for a 15 second delay before the door will unlock, once the releasing device (crash bar) is activated. Although the Life Safety Code does say 30 seconds is permitted if the authority having jurisdiction allows it, don’t count on this. Even if your local and state authorities permit it, Joint Commission and CMS will not. Since Joint Commission and CMS are authorities having jurisdiction, then you would need their approval as well.

ACE locks automatically unlock in the path of egress when someone approaches the door,  and also by the actuation of the manual release button which is mounted within 5 feet of the door.

So, where would a hospital use a DE lock and where would they use an ACE lock, and why?

Delayed egress locks would be used where the security needs of the patients requires a certain level of delay in an unauthorized individual trying to flee the unit, such as a nursery, pediatrics, labor and delivery or mother-baby units. The 15 second delay can alert staff on the unit that someone is trying to leave the unit who should not be doing so.

Delayed egress locks would be used in a department that has highly sensitive materials, such as medical records, or accounts receivables, or even a large storage room with valuables where the attendant cannot monitor all of the exits. The 15 second delay can alert staff in the area that someone is trying to leave the unit (or room) who should not be doing so.

Delayed egress locks can be used in patient care areas where the patients are somewhat ambulatory but do not qualify for ‘clinical needs’ locks. (Clinical needs locks are permitted in psychiatric and Alzheimer’s units.) Areas such as emergency rooms, radiology, physical therapy, and even some acute care nursing units may use DE locks to discourage those patients who are able to get up and walk around on their own, from unauthorized leaving against medical advice (AMA).

NOTE: In order to qualify to use DE locks, the entire facility needs to be protected with automatic sprinklers, OR be protected with smoke detectors.

Access control locks are typically used where access into a unit or department is desired to be locked. Consider the situation where there is a single leaf entrance door in the corridor to a laboratory which swings into the lab when opened. Access into the lab is desired to be controlled so ACE locks are installed in conjunction with a card swipe reader. The function of the ACE lock would have the magnetic lock preventing unauthorized individuals from entering the lab, but authorized individuals could swipe their ID card on the reader, which would deactivate the mag-lock and the door would unlock and they could enter. Individuals who wanted to exit the lab would approach the door and the motion sensor would sense their presence and automatically deactivate the mag-lock and the door would unlock and they could egress the lab.

Access control locks are frequently misapplied and misused throughout the healthcare industry. Often times portions of ACE locks are installed on cross-corridor doors attempting to limit access into a certain area, and the organization fails to install the motion sensor and the ‘Push to Exit’ button on the wall. All they have is a card swipe reader to release the mag-lock. This is not permitted if the locks are installed on a door in the path of egress. Take a look at the ‘Exit’ signs. If the ‘Exit’ signs direct you through a door, then it is not permitted to be locked without the delayed egress locks or the access control locks.

These comments are based on sections and of the 2000 edition of the Life Safety Code. Please refer to these sections for further details on installation and operation requirements. Also, consult with your lcoal and state authorities for other requirements concerning DE and ACE locks.

Locked Doors to Utility Rooms?

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.