Consistent Interpretation

Requirement

Environment of Care (EC) Standard EC.02.06.01: The hospital establishes and maintains a safe, functional environment.

Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.

EP 1: Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided.

Surveyor Observations

Guidance/Interpretation

Paper goods and chemicals are stored under a sink in a patient area without a prior risk assessment.

There are no standards that prohibit under-sink storage. The organiza- tion should define storage requirements based on its infection control plan, environmental risks, area served by the sink(s), product manufacturer’s recommendations for safe storage, and any applicable regulatory require- ments. Cite Standard EC.02.06.01, EP 1, when an apparent environmental

risk is found. If no risk assessment process is in use at the organization, cite Standard EC.02.01.01, EP 1. If a risk assessment has noted the problem but a correction not been implemented, cite Standard EC.02.01.01, EP 3. Note that Centers for Disease Control and Prevention (CDC) guidelines do not support the storage of medical or surgical supplies under sinks. Cite Infec- tion Control (IC) Standard IC.02.02.01, EP 4, for medical or sterile supplies.

Structural elements and equipment present an increased risk for suicide. On doors to rooms with potentially suicidal patients, there are no continuous piano hinges. Beds on a behavioral health unit/facility have cords that are five or six feet long; some have a metal lattice/springs.

Cite Standard EC.02.06.01, EP 1, when an apparent environmental risk is found. Explore the organization’s mitigation actions relative to patient safety. If no risk assessment process is in use at the organization, cite Standard EC.02.01.01, EP 1. If a risk assessment has noted the problem but a correc- tion not been implemented, cite Standard EC.02.01.01, EP 3.

Medical gas storage areas are unlocked, and empty and full oxygen tanks/cylinders are intermingled. There is an unsecured oxygen e-type tank/cylinder on a patient bed.

Cite Standard EC.02.06.01, EP 1, for interior, unsecured cylinders and storage rooms. Cite Standard EC.02.01.01, EP 5, for exterior unsecured cyl- inders or storage space. Refer to Provision of Care, Treatment, and Services (PC) Standard PC.02.01.11, EP 2, for resuscitation equipment such as crash cart oxygen. In terms of storage, a cylinder that has been opened is classi- fied as empty. There must be a physical separation of empty (opened) and full (unopened) cylinders.

The only fire extinguisher in the outpatient clinic (a business occupancy) is locked in a cabinet for which there are no available keys.

Unavailability of a fire extinguisher (such as one that is locked, with no avail- able keys) is considered a safety hazard—not a fire hazard—and is cited at Standard LS.02.01.35, EP 14, in a hospital and at Standard EC.02.06.01, EP 1, in a business occupancy.

Emergency pull cords in

patient bathrooms are either too short or wrapped around the pull bar. One patient bathroom has no nurse call device.

Pull cords should be addressed in an organization’s risk assessment, but there is no specified length required for them. Typically, they are at least 4 inches from the floor (for cleaning purposes) and no higher than 12 inches. If the devices are present, they should be installed in a way that meets patients’ needs. The only restroom locations where emergency nurse call devices are required are those in the patient room and in patient toilets, showers, and baths that are not in the patient room; however, both locations are addressed for hospital nursing units only. Nurse call devices are not

required in other areas where restrooms are present, such as a waiting room in outpatient or emergency room locations.

The decontamination room does not have a separate handwashing sink, and there are no other provisions for hand hygiene.

Prior to the adoption of the 2010 edition of the FGI Guidelines, The Joint Commission referenced the 2001 edition, where this was only a recommen- dation. If the room is new or has been renovated, cite Standard EC.02.06.05, EP 1. If the room has existed in its current state since before Jan 1, 2011, and has an effective process for hand hygiene, do not cite this issue.