Report (23) ARCHITECTS
July 25, 2017
Mr. Mark Van Domelen
Building Official
City of Tigard
Re: Elimination of Door Closers on Resident Units
Madrona Recovery Center(Building A and B)
Permit#: BUP2017-00084 and BUP2017-00092
Mr. Van Domelen %. Sw Vt/h5
Thank you for taking the time to meet with us on site two weeks ago and walk the building to
help evaluate the existing conditions and applications.As you are aware one of the items that
came up during discussion was the removal of the required door closers on the resident
sleeping rooms. Below are the paths we took to establish the rating criteria and necessity for
the closers:
• 310.6.2 Residential Group R-4, Condition 2,Alcohol & Drug Centers.
• 420.2 Separation walls. Walls separating sleeping units in the same building, and walls
separating dwelling units or sleeping units from other occupancies contiguous to them
in the same building shall be constructed as fire partitions in accordance with section
708.
• 708.3, Exception 1. Corridor walls permitted to have 1/2 hour fire-resistance rating by
table 1018.1
• 708.6 Openings. Openings in a fire partition shall be protected in accordance with
Section 716.
• Table 716.5: Minimum fire door rating in a 30-minute fire partition to be 20-minutes.
• 7.16.5.9 Door Closing. Fire doors shall be self-closing or automatic closing in
accordance with this section.
Both of the buildings are providing the code required NFPA 13 Fire Sprinkler system, and
Fire/Smoke Alarm Systems.
After discussion with our client they have decided that they would like to ask for the removal of
the closers on the resident sleeping rooms. They have prepared a letter explaining the
additional operational measures they will take and the safety risks that this population serves.
We appreciate your time and consideration in reviewing this request. If you have any additional
questions, please feel free to reach out to me.
han u. City of Tigard
Approved Plans
Kirk Sund, AIA BY- -�--- Date S- I- 17
Principal
CB Two Architects
OFFICE COPY
CB J Two Architects LLC I 500 Liberty St SE Suite 100 Salem,Oregon 97301 P:503 480-8700 cbtwoarchitects.com
macirona recovery
7000 SW Varns Street• Tigard, OR 97223
City of Tigard Permit Center
13125 SW Hall Blvd.
Tigard,OR 97223
July 20,2017
Dear Building Inspector:
As the President of Madrona Recovery,I take safety very seriously. In a highly structured and intensively
staffed, 24-hour care environment,Madrona Recovery will provide treatment services to troubled teens
struggling with psychiatric and addiction problems.Almost all the individuals whom we will serve will
present with some degree of danger to themselves(i.e.,suicide).Our"Job#1"is to keep them safe.
In accord with the Oregon Structural Specialty Code,the purpose of this letter is to request a modification
to help us succeed at Job#1.
104.10 Modifications.Wherever there are practical difficulties involved in carrying out the provisions of
this code,the building official shall have the authority to grant modifications for individual cases,upon
application of the owner or owner's representative,provided the building official shall first find that
special individual reason makes the strict letter of this code impractical and the modification is in
compliance with the intent and purpose of this code and that such modification does not lessen health,
accessibility,life and fire safety,or structural requirements.The details of action granting modifications
shall be recorded and entered in the files of the department of building safety.
Your role Is critically important
With great respect, we understand that you are charged with the administration and enforcement of
building regulations,and with that authority comes considerable responsibility.We also understand that no
matter how detailed the building code may be,you must,to some extent,exercise your own judgment in
determining code compliance.You have the responsibility to establish that the structures in which the
citizens of the community reside and the buildings in which they work are designed and constructed to be
structurally stable,with adequate means of egress,light,and ventilation,and to provide a minimum
acceptable level of protection to life and property from fire.
Fire safety codes are Important.They minimize the risk of harm to occupants.
You well know that when trying to assure people will live in a safe-built environment, it is imperative to
understand how a building is intended to be used. Permit us to elaborate on that subject.
To begin,the code classification system for buildings is based upon how the building is intended to be
used.We are classified as R-4. Because of the relatively high fire risk and potential for loss of life in
buildings classified in Groups R,the most stringent provisions for the protection of life are in these
occupancies.Most of the nation's fire problems occur in Group R buildings.More specifically, one and two-
family dwellings account for more than 80 percent of all deaths from fire in residential occupancies and
about two-thirds of all fire fatalities in all occupancies.One-and two-family dwellings also account for more
than 80 percent of residential property losses and more than one-half of all property losses from fire.There
are several factors contributing to this.
Structures in the residential occupancy usually house the widest range of occupant types(i.e.,infants to
the aged)and for the longest periods of time.As such, residential occupancies are more susceptible to the
frequency of careless acts by the occupants. In contrast, our clients will be age 12 to 17,and our staff will
all be competent adults. Our clients are expected to stay two to three weeks.They are continuously
monitored/supervised by our 24-7 staff(facility-wide ratio exceeding two staff to one client)who stay eight
to ten hours per shift. In addition, more than 23 security cameras will be strategically placed throughout
the facility and grounds to augment/enhance our surveillance abilities. Of course,for privacy's sake there
are no cameras in bedrooms or bathrooms.
Most residential occupants are asleep approximately one-third of every 24-hour period.When sleeping,
they are not likely to become immediately aware of a developing fire.Also, if awakened from sleep by the
presence of fire,the residents often may not immediately react in a rational manner and delay their
evacuation.In contrast, Madrona Recovery will have at least two staff members in each building on duty
throughout the night,awake and properly trained in emergency procedures.All our occupants will be
physically and mentally able to actively participate in a complete building evacuation during an emergency
and are capable of self-preservation. Moreover,every client will be trained in emergency evacuation
procedures,and drills will be conducted (and documented)at least once per shift per quarter(monthly).
Our facility will have fire detection and suppression(i.e.,sprinklers)systems throughout.
The fuel load in residential occupancies is often quite high, both in quantity and variety.Also, in the
construction of residential buildings, it is common to use extensive amounts of combustible materials. In
contrast, Madrona Recovery's choices in design and materials are mindful of minimizing combustibles. Our
clients'short stays will further reduce the number of belongings in the buildings. Moreover,all clients'
belongings are searched upon admission,and contraband (including any means of fire ignition and items
that are highly flammable)are sent back home with their parents.
Another portion of the fire problem in residential occupancies relates to the occupants'lack of vigilance in
the prevention of fire hazards.In their own domicile or residence, people tend to relax and are often prone
to allow fire hazards to go unabated.Thus, in residential occupancies,fire hazards tend to accrue over an
extended period of time and go unnoticed or are ignored.In contrast, Madrona Recovery staff will be
thoroughly trained in identifying potential fire and safety hazards.Formal hazard surveillance will be
conducted and documented daily.
Suicide prevention strategies are important They minimize the risk of harm to clients.
The risk of suicide in our kind of setting is estimated to be 675%higher than the risk of fire(The Joint
Commission,2017).
Inpatient suicide was the most common sentinel SENTINEL EVENTS 2005 - 2016
event reported to the Joint Commission on the
Accreditation of Healthcare Organizations over a
10-year period (1995 to 2005)and the fourth
leading sentinel event between 2005 and 2016.
In addition to the human tragedy,about 1 of 21,013 isiu► TTTTTT °=
inpatient suicides will result in a suit/claim suicide
(James L.Knoll IV,2012).Understandably,
courts and juries generally perceive inpatient
150
units as having a greater degree of control over
Fire
the patient, and thus,a greater responsibility to
prevent suicides.
The Joint Commission,the organization that provides Madrona Recovery's accreditation, explicitly
mandates that we"conduct a risk assessment that identifies... environmental features that may increase
or decrease the risk for suicide"and act to address those risk points (National Patient Safety Goal
15.01.01)(The Joint Commission,2017).
Beginning in March 2017,the Joint Commission is emphasizing assessment of ligature,suicide,and self-
harm observations in psychiatric hospitals and inpatient psychiatric patient areas in general hospitals.A
March 1, 2017,Joint Commission Online article details specific steps surveyors will take during on-site
surveys to document all observations of ligature or self-harm risks in the environment.Each observation of
a ligature or self-harm risk will be considered a requirement for improvement(RFI).Survey findings at the
highest level of risk may trigger consideration of whether an Immediate Threat to Life(ITL)exists while the
surveyors are on-site and result in denial of accreditation (The Joint Commission, 2017).
Self-closing or automatic closing bedroom doors will compromise our ability to effectively implement
protective precautions for suicidal clients.Thus, we are requesting a modification to the last item (as it
pertains to bedroom doors) in this list of interrelated codes that apply to our buildings.
• 310.6.2 Residential Group R-4,Condition 2
• 7.08.6 Openings. Openings in a fire partition shall be protected on accordance with Section 716.
• Table 716.5: Minimum fire door rating in a 30-minute fire partition should be 20 minutes.
• 7.16.5.9 Door Closing. Fire doors shall be self-closing or automatic closing in accordance with this
section.
"How will self-closing bedroom doors compromise your ability to effectively implement protective
precautions for suicidal clients?"You might ask.
For more than 10 hours of the day, closed bedroom doors will not be a problem. For safety,the doors will
be closed and locked when clients are not in their bedrooms. Clients will be actively engaged in therapeutic
activities elsewhere.However,during bedtime and occasional breaks during the day,observing/monitoring
clients who are behind closed doors is problematic.Installing viewing windows into the doors was
considered, but blind spots seemed inevitable,and the utility of viewing windows can be quickly and easily
nullified by a resourceful,desperate client with something as simple as notebook paper or a towel.
The most common method for individuals in the community to commit suicide is with firearms.Since
clients in treatment settings like ours do not have access to firearms,the most frequent methods of
attempting suicide are by hanging or by cutting themselves with a sharp object.Seventy-five percent of
inpatient suicides occur in the patient's bathroom, bedroom,or closet(Joint Commission Resources,
2007).
"How will automatic closing bedroom doors compromise your ability to effectively implement protective
precautions for suicidal clients?"You might ask. "The doors could be completely closed or completely open
until they are triggered to close by the smoke/fire detection system."
Critical areas for concern in treatment settings like ours are ligature attachment points (places from which
a person could hang themselves)—particularly any ligature attachment points in areas where clients are
provided privacy or are otherwise unobservable by staff(such as in their bedrooms with the doors closed).
Doors and door hardware(including the mechanisms used for automatic closing)are the most common
ligature points patients use to hang themselves, by far the most common method of suicide in healthcare
facilities (Joint Commission Resources,2007).
Typical Automatic Door Closer Hardware
r çji
"Why not just ask your clients if they are suicidal and check on them very frequently—at least every fifteen
minutes or so?"
"It only takes 4 or 5 minutes of adequate pressure on the carotid arteries in a person's neck to produce
death by oxygen deprivation to the brain.Thus. . . 15-minute suicide watches tend to allow a patient
sufficient time to commit suicide ...Almost any article of clothing and any protruding object can be utilized
for self-asphyxiation." (Maris RW, 1992).
A problem that is cited over and over again in sentinel event reports, peer reviews,and malpractice
litigation cases involve"inadequate monitoring and protection of new patients with moderate or high
suicide risk,or with unknown risk"(Reid, 2010). Experts caution that just asking and watching are
inadequate.
"It is important to keep in mind that even clients who respond honestly may misunderstand their own
symptoms,condition,and level of risk(Reid,2010).They may not be capable of predicting their future
condition, impulses,and behaviors, particularly in the midst of(1)a psychiatric illness severe enough to
warrant inpatient admission,and (2)a life crisis that typically precedes some admissions."
Inpatient suicide rates correlate strongly with the admission rate(Bowers L,2010).The first week of a
client's admission to the facility is considered a clear, high-risk period (Qin P,2005).With an average
length of stay of only three weeks, up to one third of all our clients at any given time will meet this risk
criterion.
Clients can and do commit suicide while on 15-minute checks.In a study of 76 patients who committed
suicide while in the hospital or immediately after discharge, 78%denied suicidal ideation when last asked,
and 51%were on 15-minute checks or 1:1 observation (Busch KA, 2003).
The physical environment itself must also be made as safe as possible.
With these considerations in mind,we respectfully request a modification such that our bedroom doors
have the ability to be open,closed,or only partially closed when clients are physically present This allows
us to individualize the safety precautions and care of each client as we hold in tension their privacy needs,
their psychiatric needs,and their fire protection needs.
During the day time, having the door partially open while the client is in their bedroom
• allows us to fully view the entire room compared to having a completely closed door
• allows us to quickly poke our head in occasionally to make our presence known
• deters the client from hurting themselves compared to having a completely closed door
• limits noise compared to having a fully open door
• provides some degree of privacy compared to a fully open door
Similarly, at night having the door partially open while the client is in their bedroom
• allows us to view their person and the entire room compared to having a completely closed door
• allows us to frequently check on their welfare without disturbing their sleep with the noise and light
associated with opening the door
• deters the client from hurting themselves compared to having a completely closed door
• allows less noise and light from the corridor, making for more restful sleep compared to having a
fully open door
• provides the perception of some privacy compared to a fully open door
Thus, we are proposing that when clients are in their bedrooms,their doors may be open, closed, or
partially closed,depending on their individual safety needs. When clients are not physically in their
bedrooms,their doors will always be closed and locked.This also includes when there is an emergency
evacuation.All clients will be accounted for and evacuated;their bedroom doors will be closed and locked
behind them.Since staff are always present in the corridor when clients are in their bedrooms,it is natural
for these actions to occur simultaneously. Our policies, procedures,and drills will reinforce this practice.
In summary, not having closers on the bedroom doors compromises the integrity of the fire partitions in the
sleeping room corridors and thus, increases the risk of harm during a fire.Our procedures and practice will
mitigate this risk.At the same time, not having closers on the bedroom doors would dramatically improve
our ability to effectively observe/monitor/protect at-risk youth and also eliminate ligature attachment
points,thus reducing the risk of a client harming themselves or committing suicide.The risk of suicide in
our setting is much greater than the risk of fire.We would very much appreciate your support in our
succeeding at Job#1 - keeping vulnerable people safe.
Thanks for your careful consideration of our individual case. We would welcome any questions and an
opportunity to explain this matter more fully,face-to-face.
Sincerely,
John Thornton, CEO
References
Joint Commission Resources. (2007).Suicide Prevention:Toolkit for Implementing National Patient Safety Goal
15A.64.
Bowers L,B.T.(2010).Suicide inside:a systematic review of inpatient suicides.J Nery Ment Dis.,198:315-328.
Busch KA,F.J.(2003).Clinical correlates of inpatient suicide.J Clin Psychiatry.,64:14-19.
James L.Knoll IV,M.(2012,May 22).Inpatient Suicide:Identifying Vulnerability in the Hospital Setting.
Retrieved from Psychiatric Times:http://www.psychiatrictimes.com/suicide/inpatient-suicide-
identifying-vulnerability-hospital-setting
Jayaram G,S. H. (2010).The utility and effectiveness of 15-minute checks in inpatient settings.Psychiatry
(Edgmont).,7:46-49.
Maris RW, B.A. (1992).Summary and conclusions:what have we learned about suicide assessment and
prediction?In B.A. Maris RW,Assessment and Prediction of Suicide. (p. 663). New York:Guilford Press.
Qin P, N. M. (2005).Suicide risk in relation to psychiatric hospitalization:evidence based on longitudinal
registers.Arch Gen Psychiatry.,62:427-432.
Reid,W.(2010).Preventing suicide.2010;.J Psychiatr Practice,16:120-124.
The Joint Commission.(2017,July 18).Behavioral Health Care National Patient Safety Goals.Retrieved from
Joint Commission:https://www.jointcommission.org/assets/1/6/NPSG_Chapter_BHC Jan2017.pdf
The Joint Commission. (2017, March 1).Now effective:Surveying,scoring of ligature,suicide,self-harm in
inpatient psychiatric setting. Retrieved from Joint Commission:
https://www.jointcommission.org/issues/article.aspx?Article=gyekSlHbR9Hi6%2fCHXVKFw2XUfze5Q3
AXIdxy7eEkh2M%3d
The Joint Commission. (2017,July 18).Summary Data of Sentinel Events Reviewed by The Joint Commission.
Retrieved from Joint Commission:
https://www.jointcommission.org/assets/1/18/Summary_4Q_2016.pdf