Door Locks for Safety Needs

As we discussed in the previous posting, the healthcare chapters of the Life Safety Code allows for three (3) special locking arrangements:

  1. Clincal needs
  2. Delayed egress
  3. Access control

The phrase ‘Clinical needs’ was always poorly defined (or not defined at all) in the 2000 edition of the LSC, and was left to the authority having jurisdiction (AHJ) to decide for themselves what doors in a hospital qualify for locking arrangement as allowed by ‘clinical needs’. Many AHJs were liberal and allowed ‘clinical needs’ locks not only for psychiatric or Alzheimer’s patients, but also for infant security as well. However, there are some state AHJs who represent CMS that did not permit the use of ‘clinical needs’ locks for infant security. That alone caused quite a bit of problems for hospital facility managers.

Well, the 2012 edition includes explanatory information (which is not in the 2000 edition) in the annex section that identifies psychiatric, Alzheimer’s and dementia patients as examples where ‘clinical needs’ locks would be allowed. It specifically did not include infant security protection. However, section of the 2012 edition says:

“Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met:

  • Staff can readily unlock doors at all times
  • A total (complete) smoke detection system is provided throughout the locked space or locked doors can be remotely unlocked at an approved, constantly attended lcoation within the locked space
  • The building is protected throughout by an approved, supervised automatic sprinkler system
  • The locaks are electrical locks that fail safely so as to release upon loss of power to the device
  • The locks release by independent activation of a smoke detection system or waterflow in the automatic sprinkler system”

The Annex section of does state pediatric units, maternity units and emergency departments as examples that qualify foir ‘safety needs’ locks. Now, the Annex section is not part of the enforcable code, but it does offer guidance and direction for AHJs to follow on their over-all interpretation of the the LSC. This new section in the 2012 edition should solve the debate if a nursery or pediatric unit can be locked.

Changes With Electrically Locked Doors

Electrically locked doors. The 2000 edition of the LSC does not discuss them, directly. However, it does talk about the three types of locks that are permitted in hospitals: 1). Clinical needs; 2). Delayed egress, and 3). Access control.

Access control locks are the most misunderstood locks in hospitals today, and I would say nearly all the hospitals that I visit, have some sort of deficiency with access control locks. Let’s review quickly what is required for access control locks: A motion sensor on the egress side; A wall-mounted ‘Push to Exit’ button within 5 feet of the door; When the ‘Push to Exit’ button is depressed, it interrupts power to the lock for a minimum of 30 seconds; A loss of power to the control system renders the lock disabled; And activation of the building’s fire alarm or sprinkler system automatically unlocks the door. Nearly all of the access control locks that I have seen in my career utilize magnetic door locks, or mag-locks for short. These access control locks end up being a problem for facility managers because they get installed by well-intentioned, but poorly informed individuals who do not consult with the person who is knowledgeable on the Life Safety Code.

Now, when the 2012 edition of the LSC is adopted, there will be a new version of door locks, that will solve a lot of these problems. The three locks permitted in hospitals (clinical needs, delayed egress, and access control) will remain, but Chapter 7 will now permit doors that are ‘electrically locked’ to be considered the same as any other normal lock on the door. Section says:

“Door assemblies in  the means of egress shall be permitted to be electrically locked if equipped with approved, listed hardware, provided that all of the following conditions are met:

  • The hardware for the occupant release of the lock is affixed to the door leaf
  • The operation has an obvious method of operation that is readily operated in the direction of egress
  • The hardware is capable of being operated with one hand in the direction of egress
  • Operation of the hardware interrupts the power supply directly to the electric lock and unlocks the door assembly in the direction of egress
  • Loss of power to the listed releasing hardware automatically unlocks the door assembly in the direction of egress
  • Hardware for new installation is listed in accordance with ANSI/UL 294.”

Now it is important to note that this section is under the heading of “Locks, Latches and Alarm Devices” (2012 edition) and is not under the the heading “Special Locking Arrangements”. That implies this new ‘electrically locked door’ section is not considered a special locking arrangement, but places it squarely on the same level as regular door locks. This is significant, as the healthcare chapter (18 and 19) specifically permits this new ‘electrically locked door’ under section 18/, which says “Doors complying with 7.2.1 shall be permitted.” Well, that alone permits and does not require it to qualify as a ‘Special Locking Arrangement’ in, which includes the access control requirements.

So, the mag-lock in the picture below is the typical ‘electrically controlled lock’ used in hospitals, and when the 2012 edition is finally adopted, this lock will be allowed (in accordance with the provisions of in lieu of access control locks. However, be careful with the application and selection of equipment. The electronic ‘touch-sensitive’ crash bar in the picture above, probably would not be permitted, as a person wearing a glove would not be able to make the completion of the electrical circuit that bare skin requires. Also, those applications where a card-swipe reader or a proximity reader is used in conjunction with a mag-lock will not qualify for the ‘electrically controlled locks’, as those locks require the use of a special tool. Section (2012 edition) still does not allow the use of a special key or tool to operate the lock.


Patient Room Door Locks

Q: Are dead-bolt locks permitted on patient room doors, to keep unauthorized people from entering the rooms? We have dead-bolt locks on the patient room doors in our behavioral health unit which can be unlocked from the corridor side with the use of a key, and the dead-bolt can be unlocked from inside the room with a thumb turn device. These locks are separate from the door latch and are mounted about 60 inches above the floor.

A: While dead-bolt locks on patient room doors that require two actions to operate the door are not permitted in most applications, dead-bolt locks for clinical needs as you described would be allowed by some authorities having jurisdiction (AHJ). Section in the 2000 edition of the LSC does allow locks on patient room doors provided they are operable by staff from the corridor side and the lock does not restrict egress from the room. So far that does describe your arrangement, but we need to take a look at section that describes the latch or other fastening device (i.e. the dead-bolt lock) is required to be located not less than 34 inches and not more than 48 inches above the floor, and the door must be operable with not more than one releasing operation. In your situation the dead-bolt lock that is separate from the door latch mechanism does not meet this requirement because the lock is mounted more than 48 inches above the floor.

However, the National Fire Protection Association (NFPA) Healthcare Interpretations Task Force (HITF) made an interpretation in June, 2008 that allows dead-bolt locks that require two actions to operate the door where clinical needs locks are used, which included behavioral health units. The problem with this interpretation is they did not address the dead-bolt lock that is mounted more than 48 inches above the floor, as referenced in Joint Commission is on record as saying they will abide by whatever the HITF decides, but CMS does not have the same endorsement. They have said they will abide with the decisions of HITF when it is consistent with their own interpretations. In addition, there is no representation of state AHJs from the department of public health (or other similar agency) on the HITF, so each state AHJ has their own interpretation on this issue that may be different than the HITF. My advice, in order to be in compliance with door locking requirements, you will have to consider using the combination door latch / dead-bolt mechanism typically found in hotel rooms, that meets all of the requirements found in

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 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 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 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 for delayed egress locks and section 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 ( 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 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 refers us to section 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 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 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.