Locks and Latches on Doors

Q: In follow up to your articles on locks on doors, we are a mental health facility and have mag-locks operated by swipe cards / fobs. The same doors also have latching hardware operated by push bars and thumb releases. Is this in conflict with “no more than one releasing operation to operate the door”?

A: That is a good question… I would say a door that is equipped with magnetic locks and has basic latching hardware does qualify as a door with more than one action to operate the door. But, as I said many times, it doesn’t matter what I say… it matters what your authorities having jurisdiction (AHJ) say. While of the 2012 LSC does allow two additional releasing operations for security devices, that only applies to individual living units and guest rooms of residential occupancies. That does not seem to apply to your situation.

Section of the 2012 LSC allows doors in the path of egress to be locked where the clinical needs of the patients require specialized security measures. These sections of the LSC have been interpreted by most AHJs to be used only for psychiatric patients, or Alzheimer and dementia patients; It is not available for use in other areas of the hospital. So, the use of magnetic locks in the situation that you describe appears to be acceptable, but there is nothing in section that allows more than one releasing action to operate the door. Therefore, I would say the combination locks and latches that you describe would not be permitted.

However, I encourage you to contact your state and local AHJs, and your accreditor and ask them if they would permit the arrangement that you describe. If all of them will allow it then you are good to go. But if any one AHJ does not allow it, then you cannot have the locks and latches on the door. Make sure you maintain all the replies from the AHJs in writing for future reference.

Elopement Risk

Q: We have a potential elopement risk at the nursing home where I work. A patient gets into the stairwell and down to the first floor and exits the building. We have an alarm system that alerts us when any door is activated. My question is: Can we install interrupter gates on the second floor leading down to the first to deter elopement risk?

A: I’m not sure what you believe to be an interrupter gate … but they won’t do you any good in restricting egress. By definition, an interrupter gate cannot restrict egress. If you are fully sprinklered, you can install delayed egress locks that will slow down egress for 15 seconds, allowing staff to respond to the local alarm and prevent someone from leaving. For normal egress you can provide authorized people ID badges that can be swiped or read on a card reader bypassing the delayed egress locks. You may even consider specialized protective measure locks as described in section of the 2012 LSC. They may cost you more, but they are effective for your concern.

Patient Bathroom Door Locks

Q: I currently serve as plant operations director at a nursing home in east Tennessee. State surveys questioned the locking arrangement on bathroom doors used both by the public and the patients in the facility. Looking in the 2012 Life Safety Code, I cannot find anything that prohibits locks on patient room doors. Will you please help with this issue?

A: If you are asking if the LSC prohibits locking of doors to bathrooms used by patients and/or visitors, then I would say the code is very silent on the subject. When the code does not prohibit something, then the AHJ can interpret this as meaning the code permits it.

But the issue of locking bathroom doors for patients is considered a patient safety issue, and is subject to surveyor discretion in accordance to the CMS Condition of Participation §483.70 Physical Environment for maintaining a safe environment. Conceivably, a patient could lock themselves in a bathroom and then become incapacitated and need assistance. If staff does not have an immediate method to gain access to the bathroom, then the patient is placed in an unsafe environment.

Some facilities resolve this issue by providing keys to each healthcare worker and expect them to carry them on their person at all times. This way, any healthcare worker can gain access to a patient bathroom in the event of an emergency. What code or standard did the state surveyors reference when they mentioned they had a problem with this arrangement? Get that code or standard reference from them and follow-up and see if you actually comply with that requirement.

Push & Turn Deadbolt Locks

Q: Is it legal for a deadbolt lock to have a thumb turn on the inside where the user needs to “push and turn” to open rather than just turn as it is on other deadbolt locks?

A: Section of the 2012 LSC says doors must be able to be operated with not more than one releasing operation, unless otherwise specified. Section says two releasing operations are permitted for existing hardware on a door leaf serving an area having an occupant load not exceeding three persons, provided that releasing does not require simultaneous operations.

NFPA does not define what a ‘releasing operation’ actually is, but I think a successful point can be made that a push and turn action could be considered a single action or operation. It all depends on the surveyor or inspector surveying your facility.

Wedging Doors Closed

Q: Is it allowed to use door wedges to keep the exam doors locked? If an intruder enters our hospital, there was some talk about using the door wedges to lock the doors so the intruder cannot open the doors. It was also brought up that if one person was in the room and used a door wedge and had a medical emergency, the door could not be opened to help the person. Any help you could give us would be greatly appreciated?

A: During normal operations, it would not be acceptable to wedge a door closed to an exam room or a patient sleeping room as that would cause an unsafe environment, and would likely be cited under CMS Condition of Participation standard §482.41(a) for an unsafe environment. Your intuition is correct: A wedged door would cause delay in gaining access to a patient in distress.

However, during an emergency, all “bets are off”, meaning you do what you have to do to respond to the course of the emergency. If this means you wedge the door closed to prevent an intruder from entering the room, then that’s what you do. Although you won’t find this written in any code or standard, the concept of emergency response is you do whatever is needed to provide care and safety for your patients. Wedging a door closed to prevent an intruder from entering the room would be an acceptable plan in my book. You just don’t do that during normal operations.

Locks on Operating Room Doors

Q: Our operating rooms were constructed with deadbolt locks on each surgical room. I’m told they did this to keep someone from entering the room during a case. Since this is most likely the path of egress I can’t see this being okay by the LSC. Your thoughts?

A: I would agree with you… But there are quite of few variables here. First of all, is the OR area a suite of rooms? If so, then the doors to the operating rooms do not have to latch, and a thumb-turn handle on the egress side to unlock a dead-bolt would be permitted since there is only one action to operate the door (see of the 2012 Life Safety Code). But, if the operating rooms are not in a suite, then no, you would not be able to have dead-bolt locks because the doors would have to latch (since they open onto a corridor) and that would mean there would be two actions to operate the door: 1) To unlock the dead-bolt, and 2) Unlatch the latchset hardware.

Now section of the 2012 Life Safety Code modified some of that and says existing doors are permitted to have two releasing operations to a room serving not more than 3 occupants, provided it does not require simultaneous operations to unlock the door. But… the typical operating room serves more than 3 occupants, so I don’t see that section working for you.

I would say it boils down to whether or not the OR is a suite of rooms. If yes, then the dead-bolt locks may stay if there is only one action to operate the door. If no, then you have to remove the dead-bolt locks.

Locked Mechanical Room

Q: The computer server is located in the mechanical room. IT wants the room locked for HIPAA compliance. Is it permissible to lock a mechanical room? Doesn’t locking compromise access to electrical panels, fire panel, water shutoff, etc. in an emergency?

A: Yes… you can lock a door into a mechanical room, as far as NFPA is concerned; you just can’t lock the door in the path of egress. Does a locked door to a mechanical room restrict access to electrical distribution panels? Yes it does, but that is a good thing. According to NFPA 99-2012, section access to overcurrent protective devices (i.e. circuit breakers) serving Category 1 or Category 2 rooms must be secured to allow access for authorized individuals only. So, having these distribution panels inside a locked mechanical room meets the requirement of NFPA 99.

It is expected that authorized individuals will have a key or device to access this room in the event of an emergency. Make sure any locks that are installed on the door does not lock the door for those individuals exiting the mechanical room. It is not uncommon for Information Technology to place intermediate distribution frames containing servers in various locations around the facility. The challenge is to meet all of the requirements for limiting access for HIPAA compliance and still allow regular access for other items in the room.

Dead Bolt Locks on Office Doors

Q: Does section of the 2012 edition of the LSC, which prohibits more than one releasing actions to operate the door apply to office doors within a healthcare occupancy? For example, the nurse manager’s office opens to the corridor, and she wants to place a deadbolt lock on the door. Does the addition of a deadbolt lock create a violation? Does egress from a single office require the same “single motion” requirement as the remainder of the path of egress?

A: Yes, it does. As long as the door (no matter where the door is located) is in the path of egress, then it must comply with and be operable with only one releasing motion. A door to an office qualifies as a door in the path of egress, because if you’re inside that office, the door in in your path to the way to get outdoors. Now, it is possible that if there were two entrances (doors) to the same office, you could designate one of the doors as being in the path of egress, and the other door as not being in the path of egress. This way, the door that is not in the path of egress could have a dead-bolt lock that requires more than one releasing motion, but that may not help you with this situation.

Please understand that since this requirement to have no more than one releasing operation to operate the door is found in chapter 7 of the 2012 LSC, it applies to all occupancies, with the exception of residential occupancies as the standard states. This means it applies to your medical office buildings, administrative buildings, clinics, and as well as your hospital. Deadbolt locks that operate separately from the door latch set just are not permitted.

The 2012 LSC section does allow existing conditions where two releasing operations on a door serving an area having an occupant load not exceeding three persons to remain. But that does not allow you to install locks on that door… it is only available for existing conditions.

Rest assured, there are multiple types of locks that are available for doors that can be operated with only one releasing motion. The most common includes a deadbolt that retracts when the door handle is operated, and those are commonly found in hotels. There are other types of locks that are incorporated into the door handle and will unlock the door when the door handle is turned.

Patient Sleeping Room Locks

Q: Are locks permitted on patient room doors? Where can I locate the NFPA requirements for adding new hardware to patient room doors?

A: Section of the 2012 Life Safety Code says locks are not permitted on patient sleeping room doors. Then, an exception to this standard says key-locking devices that restrict access to the room from the corridor and that are operable only by staff from the corridor side shall be permitted. Such devices shall not restrict egress from the room. What this means is you can lock the door to a patient sleeping room as long as the person on the inside of the room can open the door and get out.

However, before you think about adding deadbolt locks to existing doors, section of the same code says you cannot have more than one lock or latch to operate the door. This means a deadbolt lock that is separate from the door latch set is not permitted because it takes two actions to operate the door: 1) Unlock the lock, and; 2) Turn the latch set handle. What you can have is a lock that automatically unlocks the door when the latch set handle is turned. These are also called hotel suite locks, because they are common in hotels. There is a deadbolt that is integrated with the latch set, and a person may unlock the door by simply grasping the latch set handle and turning.

If by chance the door in question is a fire-rated door, according to NFPA 80 you are permitted to make minor changes to the door in order to install new hardware, provided the hardware is listed for use on a fire rated door assembly.

Dead-bolt Locks on Bathroom Doors

Q: I’ve read from your column that dead-bolt locks are not permitted on doors in hospitals, but I’ve seen in other facilities where dead-bolt locks are installed on bathroom doors. Is this permitted?

A: Actually, dead-bolt locks with a thumb-turn on the inside would be permitted on restroom doors, provided the doors to the restrooms are not positive latching. Restroom doors are not required to latch, therefore the larger restrooms rarely have positive latching hardware. Section of the 2000 Life Safety Code© says doors in the means of egress are not permitted to have more than one action to operate the door. If the door had a latch-set and a dead-bolt lock then that would not be permitted since it takes two actions to operate the door (unlock the dead-bolt and turn the latch-set). But since the bathroom door does not require a latch-set, then a dead-bolt lock that can be unlocked from the egress side would be permitted.