Door Locking Arrangements
by Brad Keyes, CHSP, on Dec 9, 2020 12:00:46 AM
Q: My facility is a Rehab Hospital that may at times have patients with a memory disability. My facility has a patient Wander Guard system which is located at the entrance to the lobby. The doors are glass and have a magnetic lock when closed from the main rotunda in the hospital. Am I allowed to keep these doors closed and locked for patient security? The doors are marked with an EXIT sign above them and the magnetic locks release when the fire alarm goes off to create the path of egress.
A: No, it does not sound like you can lock those doors in the path of egress the way you are doing it. Here’s the reason why. Starting with section 220.127.116.11.4 of the 2012 Life Safety Code, it says you cannot lock a door in the required means of egress in a healthcare occupancy, unless you meet one of the following exceptions:
- Clinical Needs Locks (18.104.22.168.5.1): This section says you can lock the doors in the required means of egress where the clinical needs of patients require specialized security measures or where patients pose a security threat. Staff must be able to unlock the doors at any given time. The LSC continues on in the Annex section and in the Handbook to explain that clinical needs locks apply to patients with dementia, Alzheimer’s and substance abuse programs. While your description of one type of your patients may fall under this description, not all of your patients do. If you want to have a unit that treats both dementia patients and regular acute-care patients, then you are not permitted to use clinical needs locks to secure them in the unit. You would have to separate the clinical needs patients from the rest, and have a special unit with clinical needs locks just for them. If you do that, then you would not be able to treat acute-care patients in that unit.
- Delayed Egress Locks (22.214.171.124.1): Delayed egress locks may be used on any door in the path of egress, provided the entire building is fully protected with automatic sprinklers, and you meet the rest of the requirements found in 126.96.36.199.1. This type of lock would be a good compromise for the type of unit you describe. Once the crash bar is depressed on the door leaf, a local alarm will sound alerting staff that someone is trying to exit, and will delay the door from opening for 15 seconds.
- Access-Control Locks (188.8.131.52.2): Access-control locks may be used on any door in the means of egress, but the name is deceiving: The door is not actually locked in the direction of egress, only in the direction of ingress. This would not be a good choice for your situation.
- Elevator Lobby Locks (184.108.40.206.3): This is a special locking arrangement for elevator lobbies, and does not apply to your situation.
- Specialized Protective Measure Locks (220.127.116.11.5.2): This is a locking arrangement that is new with the adoption of the 2012 Life Safety Code and applies to ICUs, ERs, and units dealing with babies and pediatrics. While this new locking arrangement is a lifesaver (literally) for many facilities, it does not sound like it would apply to your situation.
Be careful with asking for approval from state or local authorities on any locking arrangement that does not comply with any of the above exceptions. It is observed that some state and local authorities may grant approval for a non-compliant locking arrangement, only to get the facility in trouble with CMS or their accreditation authorities.