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.

Closers on Doors to CT Scan

Q: Do entrance doors to x-ray rooms and CT scanner rooms have to be controlled by door closers?

A: According to the Life Safety Code, they only need closers if they are considered to be hazardous rooms (normally not) or if the door in question is also part of the smoke compartment barrier wall. However, other codes and standards may apply. Be sure to check with your state and local authorities.

Office Door Holiday Decorations

Q: Staff members at our behavioral healthcare facility enjoy decorating their corridor office doors (business occupancy, 20-minute fire-rated doors, multiple floors) with wrapping paper, bows, etc. affixed with scotch tape for the holidays. Are there specific prohibitions against this? We don’t want to be a Grinch unless necessary. thanks!

A: Section 7.1.10.2.1 of the 2012 LSC says decorations cannot obstruct the function of the door or the visibility of the egress components. So, the decorations cannot obstruct the door in any way.

Section 4.1.4.1 of NFPA 80-2010 says signage on fire-rated doors cannot be more than 5% of the door surface. Now decorations may not be considered signage by most individuals, but the intent is to keep the fire-load on the door to a minimum so it can function properly in the event of a fire. I can see where a surveyor would have a serious issue with decorating fire-rated doors with wrapping paper and bows, because it adds fuel to the door that was not present during the UL testing of the doors.

Sorry, but I suggest you be the Grinch and tell them to remove wrapping paper and bows from the fire-rated doors.

Round Door Knobs

Q: Our hospital has round door knobs to latch cross corridor smoke doors. I am thinking this is not okay. Does the Life Safety Code address this?

A: Other than section 12.2.2.2.3 of the 2012 LSC that requires panic hardware on egress doors (or fire-exit hardware on fire rated doors) in Assembly occupancies (or mixed occupancies that include Assembly occupancy areas) that serve 100 or more persons, there is nothing in the Life Safety Code or NFPA 80 that prevents the use of round door knobs on doors that you describe.

However, round door knobs could present a safety risk for ligature if they were located in an area where behavioral health patients are located. This risk would have to be addressed in a risk assessment and mitigation activities implemented. But the LSC does not prohibit them.

Suite Entrance Doors

Q: We have a double egress, cross-corridor door which will enter a suite under a renovation project. The suite wall is also an existing smoke barrier wall, separating smoke compartments. However, we do not want an exit route through the suite, as this would be a code violation. The new layout will not cause a dead-end corridor and the suite will house less than 50 people. Is it allowable to replace the double egress door with a pair of out swinging doors?

A: As long as the new doors are not cross-corridor doors, I believe you can have a pair of single-egress doors as an entrance to the suite in a smoke compartment barrier. Under section 18.3.7.6 of the 2012 LSC, all new cross-corridor doors serving a smoke compartment barrier must be the double egress type. But from your description, it appears these new doors would not be cross-corridor doors, but would be corridor entrance doors to the suite.

These new doors would have to latch because they are corridor entrance doors to a suite, even though they serve a smoke compartment barrier.

Anteroom Door Closer

Q: We have an isolation room next to a nurse station in the Emergency room. The corridor door to the Anteroom has a door closer on it. My question: does the closer have to be on the anteroom door? I know that it has to be on the Isolation room door.

A: According to the Guidelines for Design and Construction of Health Care Facilities by the Facility Guidelines Institute (FGI), 2010 edition, if you have an anteroom (whether or not the anteroom is required) then the door to the anteroom must have a self-closing device. The FGI does say that anterooms are not required for airborne infection isolation (AII) rooms, but they are required for protective environment (PE) room, or a combination PE/AII room. If your organization has a PE room for emergency room patients, then it would require an anteroom, which in turn would require a closer on the door. The Life Safety Code would not require a closer on the anteroom door; however, the FGI would take precedent over the LSC in this matter.

Wedging Doors Closed

Q: Is it allowed to use door wedges to keep the exam doors locked? If an intruder enters our hospital, there was some talk about using the door wedges to lock the doors so the intruder cannot open the doors. It was also brought up that if one person was in the room and used a door wedge and had a medical emergency, the door could not be opened to help the person. Any help you could give us would be greatly appreciated?

A: During normal operations, it would not be acceptable to wedge a door closed to an exam room or a patient sleeping room as that would cause an unsafe environment, and would likely be cited under CMS Condition of Participation standard §482.41(a) for an unsafe environment. Your intuition is correct: A wedged door would cause delay in gaining access to a patient in distress.

However, during an emergency, all “bets are off”, meaning you do what you have to do to respond to the course of the emergency. If this means you wedge the door closed to prevent an intruder from entering the room, then that’s what you do. Although you won’t find this written in any code or standard, the concept of emergency response is you do whatever is needed to provide care and safety for your patients. Wedging a door closed to prevent an intruder from entering the room would be an acceptable plan in my book. You just don’t do that during normal operations.