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.

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.