Immediate Jeopardy Decision?

Q: Our hospital has a room that is used for seclusion in a Behavioral Health unit. The door to this room is locked and it does not allow the patient to leave the room; only staff may release the door lock. Is this in any way an Immediate Jeopardy situation?

A: Not necessarily… Section 19.2.2.2.5.1 of the 2012 Life Safety Code allows doors to be locked in the path of egress where the clinical needs of the patients require specialized security measures or where the patients pose a security threat, provided staff can unlock the doors at all times. Clinical needs locks are permitted for use for psychiatric patients, dementia patients, Alzheimer’s patients and substance abuse patients. A seclusion room in a Behavioral Health unit would likely meet the definition for clinical needs locks, provided staff was watching the patient 24 hours/day.

Brad Keyes
Brad Keyes, CHSP

Brad is a former advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor. He guides clients through  organizational assessment; management training; ongoing coaching of task groups; and extensive one-on-one coaching of facility leaders. He analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization’s preparedness for a survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance. 

As a presenter at national seminars, regional conferences, and audio conferences, Brad teaches the Keyes Life Safety Boot Camp series to various groups and organizations. He is the author or co-author of many HCPro books, including the best-selling  Analyzing the Hospital Life Safety Survey, now in its 3rd edition. Brad has also authored a variety of articles in numerous publications addressing features of life safety and fire protection, as well as white papers and articles on the Building Maintenance Program. Currently serving as the contributing editor of the monthly HCPro newsletter Healthcare Life Safety Compliance  gives Brad further insight into the industry’s trends and best practices.