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Soiled Utility Room Security - Risk Assessment

Are soiled utility rooms required to be locked?

Any examples are for illustrative purposes only. 

The Joint Commission does not require soiled utility rooms to be locked.  Rooms that store more than 64 gallons of trash or soiled linen have doors that are self-closing and latching.  Soiled utility rooms in behavioral health units are required to be self-closing and self-locking. 

Organizations should conduct a risk assessment to determine whether locking is warranted for soiled utility rooms, other than those located in behavioral health units, to prevent unauthorized individuals access to potentially hazardous items.

 Typical criteria used to evaluate the need for the door to lock may include:
  • patient and visitor population, geriatric or pediatric patients and visitors 
  • risks residing within the room 
    • trash and linen chutes 
    • hazardous materials and waste
    • sharps containers
    • dangerous equipment
    • soiled and contaminated items

Surveillance is another form of security, the risk assessment can consider proximity to continuously staffed areas such as nurse stations, to monitor persons attempting to enter the room.

Best practice in conducting a comprehensive risk assessment would include input from infection control, risk management, the safety officer, and consulting with your local authority having jurisdiction.
Last updated on March 19, 2021
Manual: Critical Access Hospital
Chapter: Environment of Care EC

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