Length of Emergency Pull Cord

Q: Can you reference the standard, code or any information from Joint Commission, CMS or any other regulatory organization on the length of the emergency pull cord in a patient used bathroom? Thanks

A: No… The end of the nurse call cords located 4-inches above the floor is an interpretation, not a standard. It is based on the FGI Guidelines, 2014 edition, section 2.1-8.3.7.3 which says a nurse call station shall be activated by a patient lying on the floor in each room containing a patient toilet. Accreditation organizations have used the so-called “4-inch rule” as an interpretation of the FGI Guidelines section 2.1-8.3.7.3.

Since there is no specific standard that identifies the maximum or minimum distance that the end of the call-cord can be from the floor, you can set your own policy, provided it is documented and approved by your respective committees. If your own policy said 6-inches would comply with FGI Guidelines 2.1-8.3.7.3, then the surveyors would have to accept that, since their agencies have not specified the distance between the floor and the end of the cord. But if you don’t have a policy on the distance between the floor and the end of the cord, then the surveyors will assess you based on their own interpretation, which for the most part, is 4-inches. However, if your policy said something that was entirely unreasonable, then the surveyors have the right to find you non-compliant.

I suggest you have a policy that identifies an acceptable range, say 3-inches to 6-inches, to allow a little fluctuation in the field. Get your respective Safety committee and Infection Control committee to approve that policy and then the surveyors cannot cite you for non-compliance unless you’re non-compliant with your own policy.