Door Locking Requirements in NFPA 101

As published by Consulting-Specifying Engineer

Door locking can be confusing for many occupancies but can especially be daunting in health care occupancy settings due to many factors. Door locking is a complex process. Because of this, we often run across misconceptions about how separate equipment and systems come together to operate, what is and is not permitted and how to accomplish a compliant approach.

Health care occupancies have patients who are incapable of self-preservation, patients who require additional specialized security measures to protect themselves and patients who require security measures from the outside world. Caring for those patients is further complicated by a building type that is usually vast in size and includes numerous additions, expansions, renovations, and various levels of other active and passive fire protection measures including fire rated construction, fire sprinkler protection and fire alarm systems.

The result is a complex web that often leads to noncompliant door locking arrangements. In this article, we will explore the door locking requirements of NFPA 101: Life Safety Code and how to successfully apply them to health care occupancies. The 2012 edition NFPA 101 will be the focus of this piece as the Centers for Medicare & Medicaid Services requires this edition for compliance within health care occupancies.

NFPA 101 egress basics

To begin this discussion, we need to review the three basics of egress from a facility that are well defined in NFPA 101:

  • The first component typically encountered in a building is exit access, which is the portion of means of egress that leads to an exit.
  • Next up is an exit, which is either a door to the exterior in a single-story facility or a space that is separated from the rest of a structure by fire rated construction (e.g., a stair) in a multistory building.
  • Finally, once you leave a building, you will use exit discharge from an exit to a public way (e.g., a sidewalk). These components are important to understand as we talk through door locking.

Additional important background information revolves around the use of NFPA 101, which includes a chapter on means of egress (Chapter 7) for general requirements as well as detailed requirements for both new health care occupancy (Chapter 18) and existing health care occupancy (Chapter 19).

Understanding the basics of egress and where the requirements exist within NFPA 101 will allow us to explore the four main door locking approaches permitted in health care settings:

  • Access-controlled egress.
  • Delayed egress.
  • Full locking arrangements.
    • Patients with clinical needs or security needs.
    • Patients with specialized protective measures.
  • Elevator lobby exit access-controlled egress.

Before we dive into the specifics for each type of door, it is important to note that door locking requirements are focused on required means of egress doors. NFPA 101 section 18/19.2.2.2.3 will allow doors not in a required means of egress to be locked in new and existing health care occupancies.

Access-controlled egress (18/19.2.2.2.4(3) and 7.2.1.6.2)

Access-controlled locking arrangements involve electronically locked doors that restrict egress. This arrangement is commonly used in health care facilities to restrict access into controlled areas, such as emergency departments or intensive care units, and still allow egress from those same spaces under specific NFPA 101 requirements.

On the egress side of the doors where access control is used, a sensor is required to unlock the door upon detection of an occupant approaching. The door must unlock on loss of power, fire sprinkler system activation or activation of the fire detection system, if provided. In health care occupancies, fire sprinkler and fire alarm systems are required for new construction and often in existing construction as well.

However, there are always exceptions depending on the specific situation. Additionally, a manual release device located within 60 inches of the door shall be provided to interrupt power to the electronic lock for not less than 30 seconds and be readily accessible and clearly identifiable with a sign or label indicating “PUSH TO EXIT.” The egress side of the access-controlled doors in new construction will require emergency lighting.

Delayed egress (18/19.2.2.2.4 (2) and 7.2.1.6.1)

Delayed egress locking arrangements will allow a facility to hold patients/visitors/others at a door for a period of 15 or 30 seconds. Thirty seconds requires specific authority having jurisdiction approval. To use delayed egress, the building must be of low and ordinary hazard contents, which is typical for a hospital (health care occupancy).

Additionally, the entire building must be provided with either an approved automatic fire sprinkler system or an approved, supervised fire detection system. The door must unlock on loss of power, fire sprinkler system activation or activation of a heat detector or two smoke detectors.

Once force is applied to the door, the process to release the lock shall be irreversible and release upon the approved time period (15 or 30 seconds). Additionally, once activated, the door shall initiate an audible signal, which is helpful in alerting staff near the location. Specific signage is required on the means of egress side, which include the message “PUSH UNTIL ALARM SOUNDS” as well as “DOOR CAN BE OPENED IN 15 (or 30) SECONDS.” Relocking of the delayed egress device shall be by manual means only. Lastly, the egress side of the door must be provided with emergency lighting.

While the 2012 edition of NFPA 101 does not limit the number of delayed egress locks in a means of egress for health care occupancies, the adopted city or state building code may have different requirements limiting the number of devices. It is important to review all applicable codes and standards to confirm what may be required to comply.

Delayed egress is commonly used in health care occupancies to support patient and staff safety when means of egress doors cannot be locked under other locking provisions of NFPA 101. As mentioned above, delayed egress also allows staff in the near vicinity to respond to an area when a delayed egress device is activated and may require less design or building changes in fire protection features to implement in an existing situation.

Full locking arrangements

Patients with clinical needs or security needs (18/19:2.2.2.5.1 and 18/19.2.2.2.6)

The first locking arrangement permitted in health care occupancies is for situations where patients pose a security threat or where the clinical needs of patients require specialized security measures. Forensic and detection units are examples of units where patients pose a security threat. Psychiatric units and Alzheimer’s or dementia units are examples of units or areas that might have clinical needs that justify door locking.

To lock the means of egress doors in these units or areas of the health care occupancy requires the following:

  • Rapid removal of occupants by one of the following means:
    • Remote control ability of the locking devices from within the smoke compartment.
    • Keys carried by staff at all times.
    • Other such reliable means available to staff at all times. Other reliable means may include the use of a keypad or card/badge reader.
  • Only one locking device is permitted on each door in the space or unit.

Regarding the key or reliable means options, it is important to discuss with any applicable AHJs before designing or installing this locking arrangement. We have seen several accrediting organizations and AHJs indicate that these keys should be easily identified by staff if located in a pocket or in the dark through the use of a marker, tag or cap/cover.

Additionally, there should be a discussion about which staff members can be in the space during an evacuation event, which may include off unit staff such as maintenance, environmental services or visiting doctors/staff and a discussion on keys or badges/cards. The approval process should clearly document which staff members are required to have these items and identify those who aren’t, in addition to outlining what is considered a reliable means for the unlocking process.

Similar to many other items being discussed in this article, other applicable local and/or state building and fire codes may have different requirements and should be consulted as applicable.

Patients with specialized protective measures (18/19:2.2.2.5.2)

The final locking arrangement permitted in health care occupancies is for patients with special needs who require specialized security measures. Pediatric units, labor-delivery, mother-baby units and emergency departments are examples of units or spaces that require specialized security measures. To lock the means of egress doors in these units or areas of the health care occupancy requires the following items:

  • Rapid removal of occupants by one of the following means:
    • Remote control ability of the locking devices from within the smoke compartment.
    • Keys carried by staff at all times.
    • Other such reliable means available to staff at all times. Other reliable means may include the use of a keypad or card/badge reader.
  • Smoke detection is located in every space throughout the locked space or locked doors can be remotely unlocked at a location in the locked space that is constantly attended. If the smoke detection option is used, this means that every room in the locked space has detection including EVS closets, any mechanical or electrical rooms, patient rooms, etc. This is above and beyond the level of detection normally required for an unlocked space in a health care occupancy and comes with additional cost implications during initial construction as well as additional inspection, testing and maintenance costs for the life of the space. More facilities end up selecting the remote unlock option, which also meets the requirement noted above for rapid removal of occupants.
  • The building is protected throughout with an approved fire sprinkler system that is supervised.
  • Loss of power will release the locks.
  • The locks also independently release by:
    • Activation of the required smoke detection system.
    • Water flow in the fire sprinkler system.

In regard to the fire sprinkler system, there is an annex note that discusses the possibility of using this exception in an existing building that is not fully sprinklered. If this situation arises, a discussion with the applicable AHJs will be required to come to a resolution. This may include providing sprinkler protection in the locked unit or space as well as any space that may be egressed through to the exit or other items approved by the AHJ. Similar to many items discussed in this article, other applicable local and/or state building and fire codes may have different requirements and should be consulted as applicable.

Elevator lobby exit access locking arrangements (18/19.2.2.2.4(4) and 7.2.1.6.3)

NFPA 101 also permits door assemblies separating elevator lobbies from exit access to be electrically locked in health care occupancy. This provision is often used to prevent unauthorized access to various spaces within a health care facility. Many of the requirements addressed in previous sections of this piece are required for this option as well as a few others:

  • Lock must be listed in accordance with ANSI/UL 294.
  • Building is protected by a fire alarm and supervised fire sprinkler system.
  • Activation of the fire alarm occurs by waterflow in the fire sprinkler system, approved detection system in the lobby and initiation, other than manual pull stations and will release the lock.
  • Loss of power will release the lock and remain until manually reset.
  • A two-way communication system is provided in the elevator lobby that communicates with a central control point that is constantly attended by staff who are trained, capable and authorized to assist during an emergency.
  • Neither delayed egress nor access control can be applied to this locking arrangement.

Again, similar to many items discussed in this article, other applicable local and/or state building and fire codes may have different requirements and should be consulted as applicable.

Other items for consideration

Infant and child security: Specifically, when dealing within pediatric, mother baby, labor delivery or neonatal intensive care units there can be additional challenges to the door locking arrangement due to the use of infant or child security systems. These separate systems are often designed to temporary lock or hold egress doors when someone approaches within a certain range of the door.

While the security need is justified, NFPA 101 requires a balance with life safety for safe egress. There are different ways to address this depending on the locking arrangement chosen through additional coordination, connections and equipment.

Patient rooms: While this article is focused on means of egress door locking in health care occupancies, we also need to point out that door locking is not permitted on patient sleeping room doors unless:

  • Staff operable key-locking devices are permitted when the device restricts access to the room from the corridor but does not restrict access from the room.
  • Locking arrangements identified above are in place for patients with clinical needs, security threats or those who require specialized measures.

There are several different door locking arrangements that are allowed under the 2012 edition of NFPA 101 for new and existing health care occupancies. Depending on the situation and/or project, there are options that will require input from many different parties in the design and construction process as well as nursing, safety/environment of care, maintenance and other departments.

Other applicable local and/or state building and fire codes may have different requirements and should be consulted as applicable. The applicable AHJ should be included in these discussions as early as possible to assist with any gray areas or specific project conditions.

The entire process should be documented, approved and distributed to all parties that may need this information for future reference. All the locking arrangements discussed may impact the facility evacuation plan and should be included as part of this process to ensure that staff members are aware and provided with proper training.

Another important part of this process is the choosing the actual hardware and control systems used to accomplish the door locking as well as the installation. This is often complex as well and includes many applicable parties during the design and construction process. If the approved design intent is not followed during this portion of the process, there may still be issues with compliance.

Lastly, continued inspection, testing and maintenance as required by NFPA 101 and other applicable codes and standards will ensure that the compliant door locking arrangement remains that way.

Written By
Mark Chrisman

Health Sector Executive | Client Relationship Director | Principal

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