Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
220.127.116.11.5.1, 18.104.22.168.6, 22.214.171.124.5.1, 126.96.36.199.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
188.8.131.52.5.2, 184.108.40.206.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 220.127.116.11.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 18.104.22.168.2 shall be permitted.
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 22.214.171.124.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
Name: BUILDING 02 (SOUTH WING) - Component: 02 - Tag: 0222
Based on observation and interview, it was determined the facility failed to maintain required signage for delayed egress doors, affecting 1 of two stair enclosures within this building component.
1. Observation made on January 8, 2019, at 1:05 p.m., revealed the delayed egress lock at the stair tower outside room 101, lacked signage indicating Push Until Alarm Sounds, Door will Release in 15-seconds, lower level Homestead Unit.
Exit Interview with the Facility Administrator, Director of Maintenance and the Maintenance Supervisor on January 8, 2019, at 2:30 p.m., confirmed required signage was not installed.
| ||Plan of Correction - To be completed: 02/28/2019|
Facility will install approved signage to stair tower egress lock outside RM 101 to indicate push until alarm sounds, door will release in appropriate time frame.
A quarterly audit will be conducted to ensure all required egress signage is present and in good shape. Results of this will be shared in monthly QI meeting.