Pharmacy Door Locks

Q: Is it a common practice to keep pharmacy access controlled doors so they will not unlock on a fire alarm activation? Texas Pharmacy board requirements to secure medications is the reasoning behind this setup, which I feel is wrong. Narcotics are secured within the pharmacy area in a narcotics room, so the requirement for securing narcotics and meds is compliant, but I believe the main pharmacy door should release in the event of a fire alarm activation. Our fire alarm system is designed to activate as general alarm so all electrically locked doors other than the pharmacy release. Is there a standard or exception that will allow this type of set-up? The doors can be manually released from the inside, but my concern is the obstacle created by the access control when an emergent response is required.

A: You may be confusing the old NFPA 72 requirement that all doors in the required means of egress equipped with electrical locks have to unlock on a fire alarm signal. At one time, NFPA 72 did require that, but the Life Safety Code always over-rides referenced standards when there is a conflict. In actuality, the Life Safety Code governs in a situation like this. Besides, the technical committee for NFPA 72-2010 made a change to this requirement. In section 21.9.2 of NFPA 72-2010, it says electrically locked doors in a required means of egress must unlock as prescribed by other codes, laws, and standards. This is different than what previous editions of NFPA 72 said, and now NFPA 72-2010 is clear that it differs to other codes, laws, and standards (i.e. the Life Safety Code) regarding the need to unlock a electrically locked door in the means of egress during a fire alarm. There are only five (5) exceptions to 19.2.2.2.4 of the 2012 Life Safety Code, which says doors in the path of egress must not be locked:

  1. Delayed egress locks (7.2.1.6.1) which requires the door to unlock on a fire alarm signal
  2. Access-control locks (7.2.1.6.2) which requires the door to unlock on a fire alarm signal
  3. Elevator lobby locks (7.2.1.6.3) which requires the door to unlock on a fire alarm signal
  4. Clinical needs locks (19.2.2.2.5.1) which does NOT require the door to unlock on a fire alarm signal
  5. Specialized protective measure locks (19.2.2.2.5.2) which does require the door to unlock on a fire alarm signal.

But pharmacies would not qualify for clinical needs locks (used on psychiatric units), elevator lobby locks, or specialized protective measure locks (used on OB/nursery units, ICUs and ERs). That leaves delayed egress locks or access-control locks which must unlock the door on a fire alarm signal. So, your assessment is correct in that the pharmacy door in the required means of egress cannot remain electrically locked during a fire alarm signal. If you examine the Texas Pharmacy board requirements carefully, it probably says the pharmacy must be secured against unauthorized entry… not egress.

What many people forget: The Life Safety Code governs when it comes to the means of egress and over-rides other standards and codes. Getting out of the building in the event of a fire is paramount supersedes other laws, codes or standards. Why don’t you change the locks on the pharmacy doors and eliminate the electrical locks and install standard passage locks (not deadbolt locks) that do not require more than one action to operate the door? This way, the door would not be locked in the path of egress (getting out of the pharmacy) but would remain locked against unauthorized entry during a fire alarm. This is what I see other hospital pharmacies do.

Locked Exit Doors From Psychiatric Unit

Q: I am a consultant and I have a 30% sprinklered high rise hospital with locked psychiatric units. The state authority made them unlock the stairwell doors under the 2000 LSC. The stairwell doors were locked with a key. With the 2012 LSC, can those doors have delayed egress installed for security of patients or does the entire building need to be sprinklered?  The smoke compartments into the stairs in question are sprinklered.

A: No… they cannot install delayed egress locks on any door in the building because section 7.2.1.6.1 of the 2012 LSC requires the entire building to be either fully protected with sprinklers or smoke detectors. I’ve yet to find a hospital that is fully protected with smoke detectors, so it is a safe bet it is not. Since the building is not fully protected with sprinklers, then they cannot install delayed egress locks (7.2.1.6.1), elevator lobby locks (7.2.1.6.3), or specialized protective measure locks (19.2.2.2.5.2). Their only recourse is to install clinical needs locks (19.2.2.2.5.1) or access-control locks (7.2.1.6.2, but access-control locks do not lock the door in the path of egress).

 

Did the state agency explain why they could not lock the stairwell exit doors via clinical needs locks (19.2.2.2.5.1)? Perhaps the hospital did not comply with all of the requirements found in 19.2.2.25.1, or perhaps it was a personal preference of the state inspector…

Strange Observations – Part 17

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

So, here we have another exit door that is equipped with a manual latch-bolt.

I guess they wanted to keep people from using this door as an entrance, so they installed the manual latch-bolt to keep people out.

Isn’t that nice….

[Sarcasm]

 

 

 

 

 

 

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.

Strange Observations – Part 14

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

Isn’t this a winner…? I should submit this picture to Lori Greene so she can share it on her website “I Dig Hardware”.

I remember asking the staff who accompanied me during the survey why they locked this Exit door, and they said they didn’t want people going through there.

This is why we have inspections in our hospitals….

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.

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 7.2.1.5.10.4 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 19.2.2.2.5.1 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 19.2.2.2.4 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 19.2.2.2.5.2 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 7.2.1.5.10.2 of the 2012 LSC says doors must be able to be operated with not more than one releasing operation, unless otherwise specified. Section 7.2.1.5.10.6 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.