Self-Closing Doors Q&A

Question:

Do all the offices and day rooms need to have self-closing doors on inpatient psych units? I was informed that a recently surveyed hospital was cited for not having this.

Answer:

The group rooms, day rooms, and other non-locked group spaces that are not ligature resistant need self-closing and self-locking doors and a staff member needs to be always in the room when a patient is in the room.  

If you have an office that is always locked and closed unless a staff member is in the room, then that door does not need to be self-closing and self-locking and that office does not need to be ligature resistant.  

If you have a ligature resistant day room with no identified safety or self-harm risks, that room does not need to have a self-closing, self-locking door. 

In the 2018 Executive Briefing, The Joint Commission did the following Q&A:

Question – Do the offices, activity, interview, and group rooms on the inpatient psych unit need to be ligature resistant?  

NO, if:

• Self-locking and self-closing doors are installed and functioning
• Patients are under direct observation if they are in the room