Accreditation

Keyes Q&A: Corridor doors, emergency lights, and room decorations

Healthcare Life Safety Compliance, November 1, 2018

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Healthcare Life Safety Compliance.

 Editor’s note: Each month, Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, answers your questions about life safety compliance. Our editorial advisory board also reviews the Q&A column. Follow Keyes’ blog on life safety at www.keyeslifesafety.com for up-to-date information.   

Corridor doors

Q: A deficiency was found by CMS on a recent survey that stated “staff failed to provide a safe and hazard-free environment by not having all doors protecting corridor openings ready to close without impediments.” The finding was repeated three separate times as doors to a patient room could not be closed due to obstructions/impediments. In all three instances, the rooms were vacant, being used for storage, and had either a chair or wastebasket blocking the door. Although we have regularly explained away this finding with Joint Commission surveyors as being an item we train our staff on (to move obstructions in patient room doorways in case of fire while closing all doors as directed by our fire plan), the CMS surveyor listed it as a deficiency and was not satisfied with our answer. Does this seem like a reasonable action to you? The rooms were vacant, and there were no patients in them! Why would the CMS surveyor care if the doors closed or not? Do I have to attempt a zero-tolerance approach to this deficiency for all patient room doors (which would seem to be futile) or just enforce the regulation for vacant rooms only?


A: Corridor doors must close and latch at all times in the event of an emergency—even corridor doors to vacant patient rooms used for storage. I believe, given what you have described, that the CMS surveyor was correct and justified in citing any corridor door that could not close. If there is an impediment preventing the door from closing, such as a chair or a waste receptacle, then that is a deficiency. Here’s why: In an emergency, staff must quickly go through the unit, check rooms, and close doors. If there is an impediment to quickly closing the doors, and staff have to move a chair or a waste receptacle, then that slows down the process.

The concept of the corridor door is to separate the room from smoke and fire. If an impediment prevents the door from closing, smoke and fire can enter the patient room and the patient would be in serious trouble. Throughout your entire hospital, in both occupied and unoccupied units, you must enforce keeping corridor doors free from impediments that stop them from closing. I do not agree with your comment that seeking zero tolerance on this issue would seem futile. On the contrary, nurses have a very keen respect for patient safety, and if you explain how keeping corridor doors free of impediments is a safety issue, I’m sure they will buy into that and keep the doors clear.

Lastly, I’m a bit concerned that you are using vacant patient rooms for storage. Be very careful with that. If there are any combustibles stored in those patient rooms, you have a big problem, as the rooms would have to comply with section 43.7.1.2 (2) of the 2012 Life Safety Code® (LSC) on hazardous rooms. I would suggest you do not store any combustibles in vacant patient rooms.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Healthcare Life Safety Compliance.

Most Popular