Top Joint Commission Citations: Corridor Clutter, Door Wedges

The Joint Commission's focus on Life Safety Code® compliance doesn't look to be subsiding, as evidenced by fire safety provisions topping the latest list of most-cited standards in hospitals.

However, there are some simple strategies CEOs can ask their safety committees or facilities departments to look into that may help hospitals stay in better compliance.

During surveys in the first half of 2009, the top-cited standard was LS.02.01.20 (45% of hospitals receiving citations), according to the November 2009 Joint Commission Perspectives. That standard requires you to properly maintain egress routes.

Although The Joint Commission doesn't specify what concerns under LS.02.01.20 were the most troublesome, one of the likely culprits is corridor clutter, said Steven MacArthur, safety consultant for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

Watch for items obstructing corridors

Corridor exit paths must be free of obstructions, including unattended items that are not considered in use. This issue nags hospitals across the country.

CEOs should find out how often staff members on units are educated about corridor storage rules. Generally, wheeled items can only remain unattended in corridors for up to 30 minutes before surveyors will consider them in storage. There are two notable exceptions:

• Crash carts can remain in corridors at all times because they must be available for immediate emergency use.


• Isolation carts can stay in corridors outside of active isolation patient rooms at all times (once the room is empty, the cart must be relocated), which is an important provision during the H1N1 swine flu pandemic.

CEOs should also have their safety professionals verify whether fire response plans spell out where to relocate wheeled items when a fire alarm is activated, as corridors may need to be cleared for evacuations or incoming firefighters, said Thomas Salamone, director of environment of care and regulatory compliance at AKF Group, LLC, in Yonkers, NY.

Monitor fire doors improperly held open

In close second place on The Joint Commission's list of top citations is:

LS.02.01.10 (43% of hospitals receiving findings), which requires facilities to design and maintain building features to minimize the effects of smoke and fire.

Many citations under LS.02.01.10 come from a common problem: fire doors that don't properly latch closed, said Claude Baker, CFPS, fire and life safety officer at the University of Chicago Medical Center.

An easy-to-spot snafu occurs when staff members prop open fire doors with wedges or chocks, which defeat the purpose of requiring the doors to self-close or close upon activation of a fire alarm.

CEOs should ask safety committees to identify problem areas where this bad habit crops up and offer refresher education for employees if necessary, Baker said.