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Fire safety may trump ligature risk, but surveyors likely will want both


January 5, 2020

By A.J. Plunkett

During this year’s Executive Briefings in Chicago, The Joint Commission’s (TJC) newest engineering director, Herman A. McKenzie, MBA, CHSP, told hospital leadership that life safety (LS) trumps ligature risk. But be prepared to not have a choice.

Adhering to requirements in the Life Safety Code® must always take precedence over everything else, including security and ligature risk, says Brad Keyes, CHSP, owner of Keyes Life Safety Compliance.
Suicide prevention, however, is still a requirement, notes Ernest E. Allen, ARM, CSP, CPHRM, CHFM, patient safety executive with The Doctor's Company and a former TJC life safety surveyor. “CMS and Joint Commission are still focusing on ligature risks on surveys,” Allen warns.

Compliance officers in the field say they have sometimes been cited on survey for fire safety features such as door closing devices that jut out and provide a ligature point.

“If a door closer is required because the Life Safety Code requires it—i.e., a closer on a fire-rated door, or on a smoke barrier door, or on a door to a hazardous room—then the closer must remain,” says Keyes. “Now, if there is a possibility of reducing the ligature risk by using a different closer that has a different profile and does not have as much of a ligature risk, then that must be considered.”

Time waiver may be needed

Be prepared to ask CMS either directly or through your accrediting organization for a time waiver to find hardware that can meet both fire safety and ligature risk concerns (ECL 7/30/18).

“Typically, patient room doors are not required to have closers, unless it is a rare situation where the patient room door is also in a smoke barrier,” says Keyes.

“There are closure devices that do not extend out from the door and are flush with the door and frame,” says Allen. “Although the door can likely stay and not be replaced, it is still expensive to purchase new door closures and install them. In a few cases a new door frame might be required or a new door, which is much more expensive than just installing a new closure.”

Be careful when modifying an existing fire door. You must maintain the integrity of the door to act as the fire and smoke barrier it is rated to be at the start.

“There is not going to be a one-size-fits-all strategy because the design of each space can be (and often is) different,” notes Steven A. MacArthur, senior consultant for The Greeley Company in Danvers, Massachusetts.

“If for some strange reason your patient room doors are in a fire-rated wall, then those doors have to self-close and latch, which means you have to have some kind of closing device. I suppose some would opt for spring-loaded hinges, but then you can get into the dance of whether the use of the spring-loaded hinges in that application constitutes an unauthorized field modification that compromises the rating of the door,” says MacArthur.

“Generally speaking, the design of most inpatient units does not require patient room doors to self-close, so as long as it’s not part of a fire-rated assembly, then closers could be removed, though you would need to make sure that the doors still resisted the passage of smoke, which means filling screw holes, etc.,” explained MacArthur through email.

Some products better than others

Your local city or state authority having jurisdiction in fire safety may be able to offer some guidance.
For instance, MacArthur notes, the New York State Office of Mental Health (NYS-OMH) has published patient safety standards that include a lot of product information. The NYS-OMH recommends state hospitals use its online assessment of products, listed in Patient Safety Standards, Materials and Systems Guidelines Recommended by the New York State Office of Mental Health, along with a multifaceted approach.

According to the publication’s introduction, “OMH supports a multi-directed approach to the reduction of patient harm on inpatient psychiatric units including the following:

  • Completion of a patient risk assessment
  • Completion of a physical plant risk assessment
  • Ongoing staff training to ensure awareness of potential risks on units
  • Installation of products that reduce risk in all patient areas
  • Routine inspections of inpatient psychiatric units to ensure safety levels are maintained”

While not endorsing any of the products, the publication shows an array of hardware and rates it according to whether it should be used in high-, medium-, or low-risk areas, and whether it is accepted as a best practice by NYS-OMH.

You can find the 2019 edition of that guide online at https://www.omh.ny.gov/omhweb/patient_safety_standards/guide.pdf.

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