Fire doors: A critical component of life safety in healthcare facilities

by Ted Saunders

Every healthcare facility staff member should be familiar with the acronym RACE, used to provide guidelines when responding to a fire emergency. Today we will discuss one of the often overlooked and frequently cited life safety deficiencies, which is the letter C in the RACE acronym: Confine.

I cannot overstate the importance of fire doors. These doors are designed to protect hazardous areas, such as electrical/mechanical rooms, medical gas storage areas, and laboratories, as well as corridors and means of egress. In conjunction with fire walls and smoke barrier walls, fire doors confine fire, heat, and smoke to the area of origin and play a key role in safe evacuation or sheltering in place during a fire.

In addition to minimizing fire damage, these doors have historically saved lives when facilities properly maintain them. Conversely, when fire doors do not receive proper maintenance, they have contributed to numerous deaths and injuries of both civilians and firefighters.

Images 1 and 2 below show how effective fire doors can be in stopping the spread of fire when properly maintained. Note the amount of damage on the fire side of the door compared to the protected side.

Unfortunately, as important as these doors are, they are typically one of the top three life safety deficiencies for which hospitals receive citations. Specifically, fire doors in hazardous areas are the third highest-cited life safety deficiency, while fire doors in corridors and means of egress are the fourth highest. According to CMS records, they account for 15% and 14%, respectively, of all life safety violations in facilities.

Maintaining fire doors

A CMS memo dated July 28, 2017, placed special emphasis on the requirement for annual testing of fire and smoke doors in healthcare facilities as part of CMS’ adoption of the 2012 edition of the Life Safety Code^® (LSC).

Generally speaking, the 2012 LSC added new provisions under Section 7.2.1.15, Inspection of Door Openings, for the annual inspection and testing of certain fire doors and smoke door assemblies.

Life safety officers can find the procedures for conducting the annual test and inspection in the 2010 editions of NFPA 80, Standard for Fire Doors and Other Opening Protectives, and NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.

Section 3.3.95 of NFPA 80 requires a “qualified person” to inspect and test fire doors. This standard defines a qualified person as someone who, by possession of a recognized degree, certificate, professional standing, or skill, and by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.

Facilities can either hire a certified vendor in this area or train a staff person to conduct the inspections in-house. The NFPA offers a comprehensive training course for anyone desirous of achieving this certification.

Whether hiring someone or training a staff member, it is important to have as-built construction plans that include a door schedule showing the specific rating of doors, as well as a floor plan showing the location of rated doors. Regardless of who conducts the annual inspection, facilities must maintain proper documentation for each door inspected so that LSC officials and surveyors can review it.

Additional recommendations

I strongly recommend ensuring staff members are aware of the importance of fire doors and having them visually inspect doors as part of their daily routine. Important items that staff can look for are as follows:

• Doors are NOT propped open; they can only be held open with an approved device that is connected to the fire alarm system and releases the door upon activation
• Doors fully close and latch when released from an open position
• All pieces of hardware—panic bars, knobs, latching devices, hinges, etc.—are present, undamaged, and functional
• Doors and frames are free of damage or holes

Conclusion

Fire and smoke doors are an integral part of the life safety components in a facility. In order to function properly during a fire emergency, they must receive the proper maintenance. Hospitals must accomplish this through a comprehensive inspection and testing program in accordance with CMS requirements and related NFPA standards.

Ted Saunders is founder & president of Patriot Fire Protection. He is a Certified Life Safety Specialist for Health Care Managers, a Certified Fire Protection Specialist, and a Certified Fire Door Inspector.