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.

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.