HospitalInspections.org

This deficiency applies to the Legacy Building (Bldg. A-1).

Based on observation and staff interview, it was determined during the revisit that the facility failed to maintain the means of egress in accordance with Life Safety Code Section 18.2 and Chapter 7. This was evidenced by the following:

A) Egress doors equipped with Access-Controlled Egress special locking devices were not arranged in accordance with Life Safety Code Section 7.2.1.6.2, as required.

The third floor OB double security doors (Door #3D20) were arranged to have the HUGS infant abduction security system override the required motion sensor and manual PUSH TO EXIT unlocking systems. When tested during an active HUGS abduction alarm, the doors did not unlock when approached or when the PUSH TO EXIT release button was pushed. This test also documented that the manual PUSH TO EXIT release was not wired to directly interrupt power to the lock - independent of the access control system electronics, as required by Life Safety Code Section 7.1.6.2(c).

B) Locked doors in the means of egress were not equipped with Special Locking Arrangements, as required. The third floor, staff elevator lobby, corridor access doors (Door #3D19) were locked against egress from the lobby. The only manual unlocking method was by staff access control cards. The doors were not equipped with access-controlled or delayed-egress special locking arrangements. The Director of Facilities confirmed that public access to the elevators was not restricted and the doors were arranged to unlock with fire alarm activation.

C) Doors equipped with delayed-egress special locking hardware were not arranged in accordance with Life Safety Code Section 7.1.6.1, as required. The third floor Stair E (3D01) egress door was equipped with delayed egress special locking but was not continuously available for egress. Facility Security Staff stated that the door was arranged to have the unlocking function disabled upon activation of the HUGS abduction alarm.

The Life Safety Code Section 18.2.1 requires that means of egress components be in accordance with Chapter 7. Section 7.1.9 requires that any device or alarm installed to restrict the improper use of a means of egress be designed and installed so that it cannot, even in the case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 (Special Locking Arrangements).

Life Safety Code Section 7.2.1.6.1 Delayed-Egress Locks:
Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.

(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.

(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.

(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.

(d) On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Life Safety Code Section 7.2.1.6.2 Access-Controlled Egress Doors:

Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.

(a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.

(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.

(c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows: PUSH TO EXIT
When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.

(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.