Updated May 22, 2025

Information Bulletin 91-1
NH-1

Guidelines for Locked Nursing Home Units

The Minnesota Department of Health (MDH), Health Regulation Division receives requests to lock all or parts of nursing homes. This bulletin is in response to provider's desires to create a more secure area for residents who wander.   

A locked unit is considered a form of restraint

The facility must request a waiver of Minnesota Rules, part 4658.0300 from MDH Engineering.  

This waiver must comply with all provisions of these Guidelines for Locked Nursing Home Units and Minnesota Rules, part 4658.2000. 

The waiver will be reviewed and if approved and cleared by licensing, the facility may operate a locked unit.  

Determining if a waiver is needed

A waiver will be required if a unit has locked doors in the means of egress.  The locking must comply with the Life Safety Code (LSC) and MN state fire code. 

A unit in the facility that uses proximity sensors worn by residents that restricts elopement would not require a waiver.  

Facilities that are currently operating a locked unit without a valid waiver, must submit the required information to obtain a waiver. 

Submitting the request for waiver  

Minnesota Department of Health
Health Regulation Division
Engineering Services Section
health.healthcareengineers@state.mn.us 

If you have any questions, please contact 651-201-4200.  

Guidelines for Locked Nursing Home Units 

1. General
   1. Health Rule Compliance: Secured nursing home units proposed and operated for the protection and care of confused or wandering residents with a diagnosis of Alzheimer disease or similar dementia must comply with applicable rules and standards.
   2. Department of Health Engineering Approval: Locked units are subject to Minnesota Department of Health waiver approval based on submittal of information regarding program policies, physical plant, and fire safety. All locked units must be approved by the Department prior to commencing operation as a locked unit. Submittal of a waiver request can be sent to health.healthcareengineers@state.mn.us.
   3. MDH will coordinate with the State Fire Marshal (SFM) on the final inspection.
   4. Plans must be submitted to Department of Labor and Industry or the delegated authority.
2. Program Policies
   1. Physical Restraint
      1. All residents who exhibit confusion and wander are not automatically candidates for a locked unit. They must additionally exhibit an illness where treatment and care in a secure environment would be of benefit; or they display a disruptive, abusive or aggressive behavior that requires staff intervention and redirection.
      2. A locked unit, wing or floor of a facility is a form of restraint; Minnesota Rules, par 4658.0300. Only residents who require a type of secured environment based on a physician's diagnosis and written order and on other professional assessments can be assigned to such a unit. The facility shall submit a request for waiver of Minnesota Rules, part 4658.0300, in accordance with Minnesota Rules, part 4658.0040. It is recommended that the waiver request be submitted as a first step in planning for the development of a locked unit.
      3. The facility must provide immediate access and visitation by family, resident representative or other individuals, subject to reasonable clinical and safety restrictions and the resident’s right to deny or withdraw consent.
      4. The resident’s Bill of Rights states that: "Every resident shall also be free from nontherapeutic chemical and physical restraints, except in fully documented emergencies, or as authorized in writing after examination by a resident's physician for a specified and limited period of time, and only when necessary to protect the resident from self-injury or injury to others.
      5. The physicians order and related behavioral information must be entered and maintained on the residents' medical- records. It is expected that each resident’s record include:
         1. Documentation of the clinical criteria met for placement in the secured/locked area by the resident’s physician along with information provided by members of the interdisciplinary team.
         2. Documentation that reflects the resident/representative’s involvement in the decision for placement in the secured/locked area.
         3. Documentation that reflects whether placement in the secured/locked area is the least restrictive approach that is reasonable to protect the resident and assure his/her health and safety.
         4. Documentation by the interdisciplinary team of the impact and/or reaction of the resident, if any, regarding placement on the unit.
         5. Ongoing documentation of the review and revision of the resident’s care plan as necessary, including whether he/she continues to meet the criteria for remaining in the secured/locked area, and if the interventions continue to meet the needs of the resident.
      6. A resident who chooses to live in the secured/locked unit (e.g., the spouse of a resident who resides in the area), and does not meet the criteria for placement, must have access to the method of opening doors independently. Staff should be aware of which residents have access to opening doors and monitor their use of the access to ensure other residents’ safety.
3. Written Policies
   1. There must be policies with criteria and procedures for admission and demission of residents to and from the unit.
   2. A plan of care, based on a thorough assessment, must be written for each resident. It must include a statement of the behavioral reasons for which the resident is placed in the unit, their causes, and the goals to be accomplished. The treatment plans must be designed to correct or compensate for behavioral problems. Guardians and family members must be consulted when developing the plan of care.
   3. A policy for ongoing observation by staff or any member of a disciplinary team for the need of continued placement of each resident in the locked unit, including a policy for specific time periods for formal reassessment of such need, must be provided. Review of residents should be at least quarterly.
   4. A schedule of the staffing pattern within the unit, must be provided. There must be one or more nurses on duty 24 hours/day.
4. Physical Plant
   1. Residents in a locked unit are entitled to the same physical plant provisions as residents in other units of the nursing home. The unit must therefore be self-sufficient with its own space and service areas.
   2. Actual size of a proposed unit (i.e. number of beds) must be supportable by medical records and other documentation of established need. A floor plan that permits flexibility in unit size could be advantageous.
   3. There must be a nurse station within the unit with space for records and medications, and nurse calls must register at that station. In a small unit of a wing, when all bedroom dome lights are observable from the unit's nurse station, calls from an existing nurse call system may continue to register at a central nurse station located outside the unit on the same floor. Nurse calls from a secured unit cannot be answered only from a nurse station outside the unit.
   4. Nursing utility rooms, including bathing areas must be available within the unit, unless there is a written policy for residents to be escorted elsewhere for bathing.
   5. One or more lounge areas with a total of 20 sq. ft. per resident must be provided within the unit.
   6. One or more dining areas with a total of at least 10 sq. ft. per resident is required within the unit unless there is a written policy for supervised use of dining room space outside the unit.
   7. A connected, secured outdoor area is recommended.
5. Fire Safety
   1. A locked unit must meet the State Fire Marshal's "Guidelines for Locked Patient Areas in Nursing Homes"
   2. To obtain approval from the State Fire Marshal Division, contact the Deputy State Fire Marshal Healthcare Supervisor, at 507-308-4189 or via email at FM.HC.Inspections@state.mn.us
   3. The fire safety system must be reviewed and approved by the State Fire Marshal prior to commencing operation as a locked unit. 

Minnesota State Fire Marshal Division Guidelines for Locked Patient Areas in Nursing Homes 

In order to provide secure areas for the confinement and protection of Alzheimer's patients, and/or confused and wandering patients, exits, exit access doors, and smoke barrier doors may be locked in accordance with the following guidelines pursuant to Sections 18.2.2.2 and 19.2.2.2 of the 2012 Life Safety Code.    

These guidelines are intended only for the locking of doors of a single wing, or section of a building, and may be implemented only after approval from the State Fire Marshal Division, the local fire authority and notification to the Minnesota Department of Health. Notification and approvals by all parties must be in writing.   

1. A manual release is required on both sides of the locked doors. The manual release of these locks may be accomplished by one of the following:
   1. Touch and color-coded key. Each employee assigned to or working on the floor or wing must be assigned-their own key which must be carried at all times when on duty. Multi facility campus door locks must be keyed alike.
   2. The use of a digital keypad using a maximum of four (4) digits or numbers. An example of an easily remembered code would be the current year, e.g. 2025.
   3. A conveniently located push button near the locked door. It shall be accessible to all visitors and staff. (Generally located toward the top of the wall or frame on the latch side of the door).
   4. Remote release from the nurse's station. 

Note: When using any of the above, the locked doors shall not require two simultaneous operations, or two-handed operation. 

2. The locks must automatically release upon activation of the building fire alarm system.
3. Stairway doors and horizontal exits shall have their latching mechanism remain functional at all times, even when the fire alarm is activated.
4. Smoke detectors connected to the building fire alarm system shall be installed 30 feet on center, in the corridors of the affected wing or section. The installation of these detectors shall be in accordance with National Fire Protection Association (NFPA). There are two exceptions to this:
   1. Exception 1: Where each patient sleeping room is protected by such an approved detection system and a local detector is provided at the smoke barrier and horizontal exits, such corridor systems will not be required on the patient sleeping room floors.
   2. Exception 2: Buildings protected throughout by an approved automatic sprinkler system installed in accordance with Section 9.7 of the 2012 Life Safety Code.
5. When the locked patient area consists of a wing or section of a floor, there shall be a smoke detector located within five (5) feet of, and outside of, the locked wing entrance door(s). A smoke detector will not be required at street level outside doors or at stair door(s).
6. Manual fire alarm pull stations shall be located inside the wings near all the locked exit doors.
7. All other provisions of the fire code will be complied with. 

Deviations from these guidelines will be addressed on a case-by-case basis and may require a waiver or variance. 

Any questions on these guidelines should be directed to the Deputy State Fire Marshal responsible for the inspection of the facility.