Corridor Doors

Q: I have a healthcare occupancy under existing construction. The building was built back in the 50’s and 60’s, with a major renovation in 1992. The available plans have indicated the fire-rated walls and doors, but there are other doors not specifically designated as smoke doors or fire-rated doors. My question is, what doors would fall under the description of corridor doors? Would it be all doors that exit directly into the egress corridor? Some of these doors are to normally occupied offices, some are to patient rooms, and some are to conference rooms that are only occupied during meetings.

A: Corridor doors are those that separate the corridor from a room, suite, or area. They are not cross-corridor doors that separate a corridor from another corridor. Do not be fooled by a double set of doors, as they can be either corridor doors (an entrance to a room, or suite), or cross-corridor doors (smoke barrier doors, or privacy doors in a corridor).

Here is a summary of the Life Safety Code requirements for corridor doors:

  • Corridor doors must comply with section 19.3.6.3 of the 2012 LSC, and have certain requirements that they must meet, such as:
    • They must resist the passage of smoke (no holes in them)
    • They must be 1¾-inch thick, solid-bonded wood core
    • Constructed with materials that resist fire for a minimum of 20 minutes (NOTE: This does not mean the corridor doors must be 20-minute fire rated).
  • Corridor doors to toilet rooms, bathrooms, shower rooms, sink closets and similar auxiliary spaces that do not contain flammable or combustible materials are not required to comply with the above requirements.
  • In smoke compartments protected throughout by automatic sprinklers the corridor door construction requirements listed above are not mandatory, but the corridor doors must resist the passage of smoke (no holes).
  • Corridor doors are not required to meet the NFPA 80 standards for fire-rated door assemblies, unless the door also serves a fire-rated barrier.
  • The clearance between the bottom of the corridor door and the floor (i.e. undercuts) must not exceed 1 inch.
  • The corridor doors must have positive latching hardware.
  • Corridor doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials are not required to have positive latching hardware.

You will notice section 19.3.6.3 does not say anything about self-closing devices for corridor doors, because they are not required on corridor doors, unless the corridor serves another purpose, such as a smoke barrier, horizontal exit, or hazardous area.

Check with your state and local authorities before you make any modifications, to determine if they have other regulations or requirements regarding corridor doors.

Window Frame Rating

Q: Can you verify what a window frame rating should be in a 1-hr load bearing wall? Does the frame need to maintain the 1-hr rating of the wall or can it be 45-minutes? This window is in a load bearing wall that separates a corridor from an office.

A: Since windows are openings in fire-rated barriers, I turn to NFPA 80-2010, section 17.1.3 on window frames. This section says fire window frame assemblies must be permanently labeled for such use. The Annex section of A.17.1.3 says the labeled assembly includes the frame and can include a ventilator, glazing material, retaining members, mullions, and hardware, if applicable.

The label reading ‘Fire Window Frame’ includes the design and construction of the frame, ventilator, glazing material retaining numbers, and hardware. Table 8.3.4.2 of the 2012 Life Safety Code provides the minimum fire protection ratings for opening protectives in fire-rated barriers. According to “Exit Access Corridors” on this table, fire window assemblies in 1-hour corridor walls are permitted to be ¾ hour fire rated. So the frame would also be ¾ hour rated.

Fire Rated Door Assemblies

Q: You have stated in previous Q&As that all fire-rated door assemblies must be tested and inspected. I don’t think that is true on fire-rated door assemblies that are not located in a fire-rated barrier. I was under the impression that the hospital’s current Life Safety drawings would be the determining factor on what barriers the hospital was responsible for maintaining. For example, if the building had rated doors on a wall that was not denoted as a fire rated barrier on the LS drawings, one could justify why there were not maintained. I run into the installation of unnecessary rated doors in many facilities, both old and new.

A: You make an interesting case. However, the Life Safety Code always trumps everything else, and in this case it would trump the hospital’s LS drawings. According to section 4.6.12.3 of the 2012 LSC, it clearly says all existing features of life safety that are obvious to the public, if not required by the LSC, must be maintained or removed. And section 8.3.3.1 says openings (i.e. doors) required to have fire protection must be maintained in accordance with NFPA 80 which requires annual testing and inspection.

Now, there’s a lot going on with this statement… For example: NFPA has said via informal comments that a fire-rated label on the edge of the door is not considered ‘obvious to the public’. But other AHJs disagree, and have stated that the fire-rating label on the door constitutes the need to maintain it as a fire-rated door. Most surveyors will go by the fire-rating label on the door, since a high percentage of Life Safety drawings are inaccurate to some degree.

I don’t disagree with your logic. If it were up to me, I would not require fire-rated doors that are not in fire-rated barriers to require testing and inspections. But think of it the way a surveyor does… Who is to say the fire-rated doors are not located in a fire-rated barrier? Just because the Life Safety drawings say it is not in a fire-rate barrier, what about building code requirements? Life Safety drawings do not always represent the rated wall requirements of building codes. There is too much ambiguity for a surveyor to take the word of the hospital that a certain fire-rated door is not located in a fire-rated  barrier.

My advice is to remove the fire-rated label from the door and frame if the facility is sure the door assembly is not located in a fire-rated barrier.

Med-Room Corridor Door

Q: As I understand the Life Safety Code, doors opening from a patient floor corridor into a patient room do not have to latch. I have a room next to a patient room that we call a support room. It contains meds, a sink and an ice machine and has to be secured. It is not a rated opening, has a closure and is secured with a mag lock and keypad and has two ways to egress when in the room. Is this a OK scenario?

A: No… that scenario is not correct. The room you described must have a door that separates it from the corridor, and the door must latch. Take a look at 19.3.6.1 of the 2012 Life Safety Code that says corridors must be separated from all other areas by partitions unless otherwise permitted by one of the nine (9) exceptions. The med room is not one of the nine exceptions. Therefore, according to 19.3.6.3.5, the door must latch. You say it is equipped with a magnetic lock. Keep in mind a magnetic lock is not an acceptable substitute for a latch. If installed in accordance with section 7.2.1.6.2 (access-control locks, having a motion sensor and a ‘Push to Exit’ button on the egress side), then the magnetic lock is permitted, but the door still needs to have a latch. CMS does not permit the allowance for existing doors to not have positive latching hardware provided a force of 5-lbs. is applied to the latch edge.

Whoever told you that patient room doors do not have to latch was wrong. Patient rooms are also required to be separated from the corridor according to 19.3.6.1, and have doors that must latch, according to 19.3.6.3.5.

Doors to Operating Rooms

Q: We have two open-heart OR’s. Each has a full 42″ wide door leaf that open to the corridor, and each has a 3’0″ door in the rear of the OR that opens into a central sterile core. The OR walls other than the corridor side are not labeled as a fire/smoke barrier on the life safety drawings. The main OR entrance door that opens into the corridor has a door closer, is rated, and has latching hardware. My question is: The 3′ 0″ doors opening into the sterile core have closers but do they have to be fitted with latching hardware?

A: Not necessarily, provided the sterile core area is qualifies as a room or a suite-of-rooms. What does the life safety drawings say about the sterile core area? Is it classified as a suite? If so, then you should be fine without a latching door between the OR and the sterile core area.

However, if the life safety drawings clearly identify the internal walls of the sterile core area as corridor walls, then the door between the OR and the sterile core area would have to latch. Remember: All corridor doors must latch.

My guess is, the sterile core area probably qualifies as a suite-of-rooms (see section 19.2.5.7 in the LSC) or if small enough, it may qualify as a simple room. As long as the 3’0” door from the OR does not open onto a corridor, then it does not need to latch.

Fire-Rated Frames

Q: I’m confused… does the door frame in a fire door have to be labeled, when 100% sprinkled with 1-hour fire-rated assemblies are in place with a 45-minute labeled door ?

A: First of all… the building being sprinklered has no bearing on this issue.

Secondly, yes, the frame must be labeled as a fire-rated frame when the door assembly is a fire-rated door assembly. In other words, if the door itself is a labeled fire-rated door, then the frame also must be labeled.

Now, most fire-rated frames are identified with a label that says the frame is fire-rated… it will not say the frame is a 45-minute frame or a 90-minute frame. There are some exceptions to this, but most frames are not labeled with a fire-rating in minutes or hours… they are just labeled as fire-rated frames.

Strange Observations – Part 12

Continuing in a series of strange things that I have seen when consulting at hospitals…

Boxes and supplies blocking a door, preventing it from closing.

Don’t know what the circumstances were in this situation, but it will likely get the hospital in trouble.

Corridor Doors

Q: A deficiency was found by CMS on a recent survey that stated ‘staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings ready to close without impediments’. The finding was repeated three separate times as doors to a patient room could not be closed due to obstructions/impediments. In all three instances, the rooms were vacant, being used for storage, and had either a chair or waste basket blocking the door. Although we have regularly explained away this finding with Joint Commission surveyors as being an item we train our staff on (to move obstructions in patient room doorways in case of fire while closing all doors as directed by our fire plan) the CMS surveyor listed it as a deficiency and was not satisfied with our answer. Does this seem like a reasonable action to you? The rooms were vacant, and there were no patients in the rooms! Why would the CMS surveyor care if the doors closed or not? Do I have to attempt a zero-tolerance approach to this deficiency for all patient room doors (which would seem to be futile) or just enforce the regulation for vacant rooms only?

A: Corridor doors must close and latch at all times in the event of an emergency. Even corridor doors to vacant patient rooms used for storage.

I believe by what you have described, that the CMS surveyor was correct and justified in citing any corridor door that could not close. If there was an impediment blocking the door, such as a chair or a waste receptacle preventing the door from closing, then that is a deficiency. Here is the reason why… In an emergency, staff must quickly go through the unit and check rooms and close doors. If there is an impediment to quickly closing the doors, and the staff had to move a chair or a waste receptacle, then that slows down the process. The concept of the corridor door is to separate the room from smoke and fire in the corridor. If an impediment prevents the door from closing, then smoke and fire can enter the patient room and then the patient is in serious trouble.

You must enforce maintaining the corridor doors free from impediments to close them throughout your entire hospital, on units that are occupied and units that are not. I do not agree with your comment that seeking a zero-tolerance on this issue would seem futile. On the contrary, nurses have a very keen respect for patient safety, and if you explain keeping corridor doors free of impediments is patient safety, then I’m sure they will buy into that and keep the doors clear.

I’m a bit concerned that you are using vacant patient rooms for storage. Be VERY careful with that. If there are any combustible stored in those patient rooms, you have a big problem. The room would have to comply with section 43.7.1.2 (2) of the 2012 LSC on hazardous rooms. I would suggest you do not store any combustibles in vacant patient rooms.

Two Releasing Devices for Doors

Q: I heard in a webinar that under the 2012 edition of the Life Safety Code, I can you have two releasing devices on doors. Is this true?

A: Yes, it is true, but only in very limited situations is it permitted. A new section (7.2.1.5.10.6) of the 2012 Life Safety Code allows two releasing operations to be permitted for existing hardware on a door serving an occupant load not exceeding three persons, provided the releasing mechanisms do not require simultaneous operations. This only applies to existing conditions, and does not allow you to install deadbolt locks on doors that only serve three people. Existing means the second releasing device (i.e. deadbolt lock) was on the door prior to July 5, 2016.

Suite Entrance Doors

Q: A hospital has 2 different suites with double egress entry doors and the Joint Commission surveyor noted that these doors are supposed to have latching hardware because they are “corridor doors,” but in my experience, cross-corridor doors are not typically required to have latching hardware.  Can you weigh in on this?

A: I agree totally with the surveyor. According to the LSC, suites are nothing more than rooms; albeit a large room with smaller rooms inside. Therefore, corridor entrance doors to suites must positively latch because corridor doors are required to latch according to 18/19.3.6.3.5, 2012 LSC.

The thing that throws people off is what looks like a corridor inside a suite is not a corridor; it is a communicating space. The requirements of a corridor do not apply inside a suite. But the designers often make this space 8 feet wide and for all intent and purposes people think it is a corridor. Then, the designer places double egress doors as entrances to the suite (which is good when you’re pushing patients in an out on beds) and the doors look like cross-corridor doors. They’re not; they are corridor doors.

The hospital has to make those doors positively latch or they have to change the designation from a suite to a corridor, which is not advisable.