As healthcare facility managers, you understand the importance of maintaining a safe environment for your building occupants and patients by stringently inspecting and maintaining your life safety systems, but are the rest of the staff aware of these systems as well? Patient safety depends on a combination of existing fire and life safety features along with staff awareness and response. Some of the most common citations given out by TJC and CMS are inadvertent mistakes made by hospital staff. These mistakes are easy targets for AHJs during their surveys, but it could also be the difference between life and death during a true emergency.
Here are some common mistakes that the staff in your facility might be making:
Obstructed Egress Corridors
Many facility employees may be carting supplies, meals for patients, or tools throughout the corridor. These items are often left in the corridor while they are in use, which is allowed only for short periods of time. For example, a wheelchair may be left parked outside a patient room when preparing to transport them to another area. However, leaving these items in the corridor unattended for long periods of time could result in an egress obstruction, making it difficult for employees or patients to evacuate during an emergency.
Items that are parked in the corridor for more than 30 minutes will definitely result in citations by AHJs during their surveys. According to George Mills, Director of Engineering at TJC, there are only two exceptions to this rule: crash carts and infection control isolation carts. Crash carts are allowed to remain in the corridor for easy access by an employee with an arrangement to be moved out of the corridors in the case of an alarm or necessary evacuation. Infection control carts can also remain in the corridors as long as they are being used to isolate an infectious patient’s room.
Visibly Damaged Fire-Rated Doors
A high frequency use door can experience between 400 to 5,000 cycles per day, or 118,000 to 1,500,000 cycles per year. With constant movement through corridors and hallways, fire-rated doors can easily become damaged from traffic, supply carts, gurneys, and more. What may seem like small or insignificant damage may be enough to cause the door to lose its technical rating, and affect its ability to hold back smoke and flame in the instance of a fire. Even a fraction of an inch difference in door clearance can make a huge difference in compliance and rating.
Staff members may unknowingly be damaging fire-rated doors, and not reporting it to their facility managers to be fixed, because they may not know the potential for risk it could hold. Simple fixes, such as clearly labeling fire-rated doors, could bring more attention to facility employees. Making employees aware of potential door citations would urge them to use more caution when going through doors or alert facility managers if they notice any damage.
When outside contractors are installing new technologies in the facility, they typically need to penetrate smoke and fire barriers to run cables, pipes, ducts, etc. When these penetrations are made, proper firestopping product should be installed to ensure the barrier is code compliant. Most contractors will seal any penetrations with firestop caulk after their work is done, however, they don’t always treat penetrations per UL specifications, and therefore is not always compliant.
Checking up on areas that you know are undergoing renovation or updates to look for proper firestopping is a good way to stay on top of things. If you don’t have the time to check out these areas yourself, train your staff on proper firestop UL systems so they can recognize and identify any issues for you. However, it may be hard to tell if a firestopping job is code compliant if hospital employees don’t know how proper firestopping should look. If you aren’t confident in the ability of your staff or the contractor’s doing work to properly seal penetrations, hire an outside specialty firestop contractor to address problem areas and ensure that your barriers are code compliant.
Knowledge is Key
Having a knowledgeable hospital staff can help facility managers better maintain their facilities. It may not be an easy task, but sharing your knowledge of life safety systems could pay off in the long run, and help you to avoid citations or save lives in an emergency. Don’t let these mistakes be an issue at your facility.
PREVENT has experienced technicians and is able to help maintain your life safety systems including: fire damper inspections & repair, fire door inspections, repair & re-certification, firestopping, and more. Request a free quote online or call us at 877-392-6074 for more information.