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Keyes Life Safety

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Converting a Room

by Brad Keyes, CHSP, on Aug 14, 2020 1:00:05 AM

Q: We are a 49-bed hospital facility (changed over from a 68-bed in 2017). Currently we have a room that was originally used for three patient beds. We are wanting to change that into an infusion treatment room. Setting up 3 recliners and a small desk area for the individual watching the patients. Looking through the different code books it seems to me that we should be fine with this scenario as long as we put a door closer on the door. If we try and store stuff in the room, we will have to make it a 1-hour fire resistive rated and treat it as a hazardous area. Is that correct or what else needs to be done? Can we put a lock on this door to secure the room at night? Any help would be greatly appreciated!

A: If you are using the room to store combustibles, you might have a problem with some AHJs if the room is also used to treat patients. While I could not find a direct standard in the Life Safety Code that prohibits patient care and treatment activities in hazardous rooms, you may find some surveyors who will consider that an unsafe practice for the patients. An AHJ may cite you under a general duty clause, such as CMS Condition of Participation CFR §482.41 that says the hospital must be constructed, arranged, and maintained to ensure the safety of the patient.

But to answer your question. If you will be storing combustible supplies in the room, and assuming the room is larger than 250 square feet, the room would have to be constructed to 1-hour fire-rated construction with a ¾-hour self-closing and positive latching fire-rated door, and the room needs to be protected with sprinklers. You may put a lock on the door as long as it does not require more than one action to operate the door on the egress side (see of the 2012 LSC). This means a dead-bolt lock would not be permitted unless the dead-bolt automatically retracts when you turn the latch-set handle.

Topics:Life Safety Code

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