Magnetic Latches on Suites

Q: We recently had an inspection in our hospital where the inspector cited us for our suite doors not having positive latching. The suite doors have 1500 pound access-control magnets controlled by card-swipe badge readers and with wall-mounted push buttons. They are on emergency power and eight-hour battery back-up. They are also approved by our local and state fire marshals. Is the inspector correct, or do I have a case for an appeal?

A: The concept of a Suite-Of-Rooms requires the barriers of the suite to be protected in the same manner as any other room bordering on an exit access corridor. Therefore, entrance doors to the suite must meet the requirements of corridor doors. In your question, you did not specify if your organization is considered a new healthcare occupancy or an existing healthcare occupancy. This is an important issue, as there are different requirements for each. If your facility’s construction documents were approved by the local authorities after March 1, 2003, then it is considered a new healthcare occupancy.

In new healthcare occupancy, section 18.3.6.3.2 of the 2000 edition of the Life Safety Code specifically requires positive latching hardware for corridor doors. The definition of positive latching is a spring-loaded throw on the edge of the door to engage in the strike plate of the door frame. Magnetic locks do not qualify as positive latching hardware. Therefore, you may not use magnetic locks in new healthcare occupancies for suites (corridor doors).

However, for existing healthcare occupancies, section 19.3.6.3.2 of the same Code specifically allows a device capable of keeping the door fully closed with a minimum force of 5 foot-lbs. Some authorities having jurisdiction (AHJ) approve of magnetic locks for this purpose as long as power to the locks is NOT interrupted during a fire alarm signal. Doors in the path of egress are not permitted to be locked except where the clinical need of the patient requires it. Not all AHJs agree on what types of patients qualify for this exception. When locks are permitted on egress doors, they must meet the requirements found in 19.2.2.2.4. The entrance door to a suite-of-rooms is permitted to be locked, as the path of egress is not allowed into and through a suite.

Magnetic locks in lieu of positive latching on corridor doors is not recommended as there are many complications and challenges in compliance, and not all of the AHJs agree on this application. It appears that a successful appeal on this issue would be difficult.

Emergency power for magnetic door locks

Q: I was recently informed by a contractor the magnetic locks that we use to lock our ER department doors are not allowed to be connected to our emergency generator power. I cannot find this exclusion to connect to emergency power in the LSC. Are you aware of this requirement?

A: What you are referring to are either delayed egress locks or access control locks, which are allowed to be used on a door in the path of egress with some limitations. LSC section 7.2.1.6.1 for delayed egress locks and section 7.2.1.6.2 for access-control locks have multiple requirements for their use, but one requirement that is shared by both sections states the doors must unlock upon loss of power controlling the locking mechanisms. Nowhere does it say that emergency power cannot be used. However, that is not the end of the story. The LSC requires hospitals to be compliant with NFPA 72 National Fire Alarm Code, (1999 edition) and section 3-9.7.3 of NFPA 72 says all exits connected with a locking device shall unlock upon loss of the primary power to the fire alarm system, and the secondary power supply shall not be used to maintain these doors in the locked condition. The Annex portion of 3-9.7.3 explains that the LSC refers to batteries in the fire alarm control panel as the secondary power supply, but the Annex portion is not part of the enforceable code, just an explanatory section. Since the LSC is silent as to whether the locks can or cannot be connected to emergency power, it is up to the authorities having jurisdiction (AHJ) to make this interpretation. It appears to me that The Joint Commission does not have a problem with delayed egress or access control locks being connected to emergency power, but I know of some state AHJs that do not allow this. I suggest you contact your state and local AHJs for their interpretations.

Locked Patient Room Doors

Q: During a recent inspection, the surveyor cited our hospital for having dead-bolt locks on our patient room doors. None of the doors were locked at the time of the inspection, but the surveyor said the doors could be locked. Our state inspectors were OK with the locks on the patient room doors as-is, but is this a LSC violation and do we have to remove the locks?

A: Section 19.2.2.2.2 (18.2.2.2.2 for new construction) of the LSC says locks are not permitted on patient room doors. However, there are two exceptions to this requirement: 1) A key-locking device is permitted as long as it restricts access from the corridor to the patient room and is operable from the corridor side, and cannot restrict egress from the room, 2) Patient room doors may be locked where the clinical needs of the patient requires specialized security measures. You did not state whether or not the dead-bolt locks could be unlocked from the room side without the use of a key, tool, or special knowledge (see 7.2.1.5.1). If they can be unlocked from the room side without the use of a key, tool or special knowledge, then I believe they would be permitted, according to exception number 1. However, if the locks are not capable of being unlocked without the use of a key, tool or special knowledge, then that would be a code violation, and the surveyor was correct. Exception number 2 allows locks on patient room doors where the clinical needs of the patients require specialized security measures, such as a psychiatric unit. In those situations, the lock does not need to be un-lockable from the inside of the room, provided the patient is under constant observation and the staff is carrying a key (or other such device) at all times to unlock the door. So, your question as to whether or not the locks need to be removed is dependent upon the clinical needs of the patients for specialized security measures, and whether or not the locks can be unlocked from the inside of the room without the use of a key, tool, or special knowledge.

Access Control Locks and Sprinklers

Q: What is the LSC stance on card swipe systems to access doors? We were told by a city inspector that we could not install access control locks because we are not fully sprinkled in the original section of our old building. In addition, if we finish installing sprinklers in this area, we were told we would need to issue keys as a backup to the access-control locks. Kind of defeats the purpose, doesn’t it?

A: It all depends on where the locks will be installed. If they will be in the path of egress, then you may have a problem. Exception number 2 under section 19.2.2.2.4 refers us to section 7.2.1.6.2 for access control locks. Access controlled locks are widely misunderstood and therefore greatly abused in hospitals. There are specific requirements of the access control locks that you must adhere to: 1) A motion sensor on the egress side to automatically unlock the door; 2) A manual release switch must be mounted 40 – 48 inches above the floor, and within 5 feet of the door. When depressed, the switch must interrupt the power to the lock for a minimum of 30 seconds. 3) Activation of the fire alarm system or sprinkler system (if provided) must unlock the doors. It doesn’t say, however, that sprinklers must be provided. If your card swipe readers are on the egress side of the locked door, and you do not comply with all of the above requirements, then you are not in compliance with the LSC. Having card swipe readers on the side of the door that is not in the path of egress is permitted. I do not see any code reference that requires you to have backup keys for access control locks. Ask the city inspector to provide you with a code reference for the interpretation. Perhaps it is a local or state requirement.

Locked Doors in the Path of Egress

Q: We have multiple paths of egress from an area used by our Bio-Med staff, and for security reasons we lock the doors to and from this area. This is a former behavioral health unit that still has the security locks on the doors. During a recent survey, an inspector cited us for having a locked door in the path of egress. The only people that travel to and from this area are two Bio-Med employees, and they always carry a key to unlock the doors. Isn’t there an exception in the Life Safety Code (LSC) that permits this arrangement?

A: No, there is not an exception that would allow such an arrangement. Locked doors in the path of egress in a hospital are only permitted in the following manner: 1) Delayed egress locks; 2) Access-control locks, and; 3) Locked doors for clinical needs. The scenario you described does not appear to qualify for any of these situations.

You may be thinking of Exception No. 1 to 19.2.2.2.4 of the LSC that permits a locked door in the path of egress where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock the doors at all times. However, your situation does not qualify for the “clinical needs” exception. “Clinical needs” is defined for the protection of patients who are a danger to themselves or others, and by many AHJs, for the security of babies. The Bio-Med employees do not qualify for this exception.

It appears to me that the inspector was correct with this citation, and my advice is to change the locks on the doors so they no longer lock in the path of egress.

Card-Swipe Reader on Access-Control Locks

Q: Regarding a recent question on access-control locks, you said the egress side of the door is required to have motion sensors and a wall-mounted “Push to Exit” button. Does it make any sense to have a card-swipe reader on the egress side of an access controlled door? Wouldn’t the motion sensor on the egress side be over-riding the card swipe reader? (Or is that the point you are trying to make?).

A: You are exactly correct… That is the point. A card swipe reader on the egress side of a magnetic-locked door is totally unnecessary, since a motion sensor and a “Push to Exit” button are required in accordance with 7.2.1.6.2 of the 2012 LSC. If you do not have the motion sensor and “Push to Exit” button then you are non-compliant. It does not make any sense to have a card-swipe reader on the egress side of a properly installed access-control lock. The card-swipe reader is indeed, pointless.