Doors to Operating Rooms

By Brad Keyes…

Q: We have two open-heart OR’s. Each has a full 42″ wide door leaf that opens 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: Does the Life Safety drawings identify the sterile core area and the operating room together as 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 the door could be fine without a latching door between the OR and the sterile core area, because it is all one suite. 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.

There is another issue here… Most sterile core areas that I have seen qualify as an hazardous area, due to the many combustible items stored in the room. If the walls surrounding the sterile core area are 1-hour fire-rated, then the door itself would have to be 3/4-hour fire-rated (see 19.3.2.1 of the 2012 LSC), and it would have to be self-closing and positive latching. If the walls surrounding the sterile core area are smoke partitions and the sterile core area is protected with sprinklers, then the door is not required to be fire-rated, but it must be self-closing (see 19.3.2.1.3) and positive latching (see 19.3.2.1.2, which references 8.4.3.2 which references 7.2.1.5.10).

Based on the information you provided, it is probable that the door between the OR and the sterile core area would have to positively latch.

Suite Doors

By Brad Keyes…

Q: Does the 2012 edition of the Life Safety Code permit existing suite doors that open into the corridor to be compliant if they do not latch shut? We have different interpretations of 19.2.5.7.1.2.

A: No. Corridor entrance doors to suites must latch. Section 19.3.6.3.5 requires all corridor doors to latch. CMS does not allow the exception for a device that holds the door closed with 5 lbs. of force.

Since a suite is nothing more than a large room with smaller rooms inside, the barrier that separates the suite from the corridor must meet the conditions for corridor walls, which means the door must latch. The provision in 19.2.5.7.1.2 (2) is written to allow existing suites to have smoke resistant walls when fire-rated barriers are required by the corridor walls.

Door Obstructed from Opening Fully

By Brad Keyes…

Q: I need you to settle an argument for us, and your answer will settle this situation for all. We have a fire door to a hazardous room, that has lockers behind it when you open the door. The lockers will not allow the door to open fully. Since this door is not in the means of egress, is this situation allowable?

A: All doors are in the means of egress as long as you can physically be inside the room. Once you’re in the room, the door is now in the path of egress to get to the outdoors. Section 7.2.1.4.1 of the 2012 Life Safety Code says all doors in the means of egress shall be capable of swinging from any position to the full required width of the opening. So, the door must swing open to at least 90 degrees. I would say your situation is not permitted and the lockers should be relocated to allow the door to open fully.

Stairwell Re-Entry

Q: I’m a Facilities Director overseeing an existing 8-story (basement included) acute care hospital fully sprinklered. We wish to mechanically lock (no auto unlock feature) floors 2-7 (Floor one being the level of exit discharge) to prevent reentry from the stairwell side. I believe there used to be an exemption from the requirements of Chapter 7 of the 2000 LSC 101 for existing hospitals that are fully sprinklered; does that exemption still exist in the 2012 version? Can I lock all 6 floors and be code compliant?

A: Section 19.2.2.2.3 of the 2012 LSC says doors not located in a required means of egress shall be permitted to be subject to locking.

Section 19.2.2.2.9 says existing healthcare occupancies shall be exempt from re-entry provisions of 7.2.1.5.8. But Annex section A.19.2.2.2.9 says doors to the stairwell on the different levels should be arranged to open from the inside of the stairwell at not less than every third floor so it will be possible to leave the stairway if fire renders the lower part unusable.

Section 7.2.1.5.8 says every stairwell that serves more than four stories must have re-entry capabilities on every floor, but the doors could be locked with electronic locks that unlock (not unlatch) on a fire alarm signal. Section 7.2.1.5.8 continues with other exceptions and requirements, but section 19.2.2.2.3 says hospital are exempt from all of that.

So, based on the Annex section, you can lock the doors from re-entry from the stairwell side, but every third floor needs to be unlocked. So, come up with a plan so every third floor door is unlocked for re-entry.

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 either the corridor, or the room. 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 combustibles 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.

Horizontal Sliding Doors

Q: Someone just asked me a question and I haven’t thought about this one before.  This AHJ is enforcing the IBC but I’m looking for an NFPA viewpoint and of course I thought of you.  The IBC and the LSC both require corridor doors in a health care facility to latch.  But what if those doors are horizontal sliding doors (manually-operated)?  The IBC allows horizontal sliding doors if the space served by the door has an occupant load of 10 or less.  The doors in question are not in suites.  I don’t see anything that prevents the use of horizontal sliding doors, or anything that says these doors don’t need to latch, but why should they have to latch since they aren’t affected by pressure the same way a swinging door would be?  It seems like latching hardware on horizontal sliding doors would be a pain for hospital staff. Have you ever run into this?

A: Yes… I see this issue a lot in hospitals. Many architects are mistaken when it comes to glass sliding doors. Perhaps they follow IBC and specify non-latching doors, but then they fail to comply with the 2012 Life Safety Code, which gets them (and the hospital) in hot water.

Section 19.2.2.2.10.2 discusses horizontal sliding doors that serve an occupant load of fewer than 10 people have to meet all of the requirements in the sub-headings 1 – 5. Sub-heading 5 says where corridor doors are required to latch, the doors are equipped with a latch or other mechanism that ensures the door will not rebound into a partially open position if forcefully closed.

So, the LSC is clear: Where corridor doors are required to latch, the horizontal sliding doors must also latch.

Yes… there are a lot of requirements in the LSC that are a pain to staff. But patient safety is a job that all have to work for, regardless how inconvenient it may be.

Power Operated Doors Do Not Have to Latch

Q: I read recently that Joint Commission allows a door with a power operator to not have to positively latch as long as it has 5-lbs. of force keeping it closed. I thought CMS already said that the 5-pound existing door exemption that’s in the Life Safety Code does not apply to CMS facilities.  Is the change that they are now allowing the 5-pound exemption on doors with automatic operators and not requiring positive latching on restroom doors?  Is it common for an automatic door manufacturer to be unable to provide positive latching?

A: I was not aware that there were any door manufacturers that could not provide positive latching hardware on power-operated doors. Apparently, the Joint Commission is aware of at least one manufacturer and made this exception to their standard. But the 2012 LSC does permit this action under 19.3.6.3.7, whereby powered doors that comply with section 7.2.1.9 (sub-section 7.2.1.9.2(5) requires powered doors to latch upon activation of the fire alarm system) are considered compliant provided the door is equipped with a means to keep the door closed that is acceptable to the AHJ, and is capable of keeping the door closed with 5-lbs. of force. But just because Joint Commission permits this (i.e. it is acceptable to them), it does not mean it is acceptable to all other AHJs. Hospitals will be taking a certain risk if they choose to go this route because it may pass a Joint Commission survey but fail a state agency survey.

You are correct in that CMS does not permit the option of a device with 5-lbs. of force to keep an existing corridor door closed, as described under 19.3.6.3.5. They have prohibited this for a few years and communicated that via informal emails to the accreditors, but did not release that information to the public as far as I know.

Certain corridor doors do not require positive latching (i.e. toilet-room doors, shower-room doors, janitor’s closets that do not store combustibles… see 19.3.6.3.6) and therefore they are permitted to have roller latches if they want. CMS and the accreditors are okay with that, although I’m not sure all surveyors fully understand that concept.

Dutch Doors

Q: I have been asked by a clinic manager at one of our primary care clinics to install a door knob on a split Dutch type door that goes into a lab area. They are requesting that the lock set be a double cylinder type where one would have to use a key to enter from the hallway as well as use a key to exit from inside of the room. I have never heard of this before (that doesn’t necessarily mean anything). I have concerns regarding egress safety, should I do this?

A: I advise you to not do this. From what you describe, it sounds to me that there would be multiple violations with this arrangement. First, having a second latch set on the Dutch door would require two actions to operate the door, which is not permitted according to section 7.2.1.5.10.2 of the 2012 LSC.

Second, it sounds like a key would be required to egress the door which is not permitted according to section 19.2.2.2.4. I’m glad you asked, but it sounds like trouble to me if you agree to install this equipment.

Downgrading Fire-Rated Door Assemblies

Q: My boss has hired an outside company that has advised him to rip fire rating labels off of doors and frames that we have maintained properly for decades. We do have automatic sprinklers in all areas. It does not feel appropriate to simply downgrade hazardous rooms, corridors, and elevator lobbies. My boss refuses to contact the AHJ and will only refer to his outside company. Is this appropriate and something I can sign my name too? Thank you for any information.

A: Well… maybe yes and maybe no.

All fire rated doors must be inspected based on 2012 LSC section 4.6.12.3 and 8.3.3.1, regardless if they are located in a fire-rated barrier or not. So, if your facility has a fire-rated door installed in a barrier (i.e. a corridor wall) that is not a fire-rated barrier, then the door assembly still has to be tested and inspected even though it is not located in a fire-rated barrier.

If you have a lot of these situations, then it can be costly to test and inspect fire-rated doors where you don’t have to, so the easy solution is to remove the fire-rating label from the door and frame. If you do that, then you don’t have to test and inspect the doors as they are no longer fire-rated assemblies. But you must be very cautious before you take such action and make doubly-sure that the door assembly is no longer needed to be fire-rated.

But you said something in your question that disturbs me… You said: “It does not feel appropriate to simply downgrade hazardous rooms, corridors, and elevator lobbies.” This statement is very troubling as you are not permitted to downgrade features of life safety that were required at the time of design or construction, unless it is a change with new construction standards. So, here is a possible scenario that may apply to your facility: When your facility was originally constructed, it was required to have all hazardous rooms be 1-hour fire-rated and fully protected with sprinklers. Today, that same room is now considered ‘existing conditions’ by definition since the 2012 LSC was adopted in July 5, 2016, and your facility was constructed prior to that date. According to the 2012 LSC, existing conditions hazardous rooms are permitted to be 1-hour fire-rated or sprinklered; not both. But section 4.6.12.2 of the 2012 LSC says no existing life safety feature shall be removed or reduced where such feature is a requirement for new construction. The 2012 LSC still requires sprinklers and 1-hour fire rated hazardous rooms, so you are not permitted to down-grade the fire-rated doors to a hazardous room just because it now qualifies as existing conditions.

You have every reason to be questioning this strategy. I suggest you and your boss contact your AHJs for guidance, or at least get some decent advice from a consultant. This outside company that you refer to… are they a qualified Life Safety company to be offering advice like this?

Some AHJs will not allow any down-grading of fire-rated door assemblies even if the doors are not required to be fire-rated, so make sure you check with them before removing any labels.

Lower Bottom Rods

Q: My department is assisting with a fire/smoke barrier door assessment. I have noticed that some of the ¾-hour corridor doors have had the lower bottom rods removed from the latching hardware with cups still visible in the floor. It is unclear why they were removed however the top latches still work and secure the door. There are small screw holes in the door as well where the hardware was removed. My thoughts are the door has been modified and no longer compliant. What are your thoughts?

 A: You are absolutely correct… By your description, the lower bottom rods were required when the door was installed, but have since been removed (They do get hit and bent by carts and are simply removed rather than replaced by poorly informed maintenance staff.) This door no longer meets the UL listing it received by the manufacturer when it was installed, and should be flagged as not passing an annual inspection.