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Seven Issues Leading to Life Safety Violations in Hospitals

Grainger Editorial Staff

According to Joint Commission Perspectives, a 2009 survey revealed that the most common types of Joint Commission standards citations given to hospitals were for Life Safety Code violations. Life Safety Code-related violations were the first, second, fourth, and sixth most frequently cited and included failure to maintain an egress as well as failing to protect people from smoke and fire. These findings are likely in part to be the result of The Joint Commission’s (TJC) increased focus in this area and the addition of Life Safety specialists to the inspection team.

What made the study troubling was that many of the citations are preventable through improved staff performance or the use of affordable solutions.

Below is a list of seven typical life safety violations along with solutions that can help keep facilities safer for patients, visitors, and staff and reduce the potential for receiving Requirement for Improvement’s (RFI) citations during the next inspection.

1. Obstructed Openings

Sometimes a stopgap solution to excess supplies is to place them next to the door and stock them later. Even in these well-intended situations, patient and staff safety can be affected since this action may allow the spread of smoke and fire beyond the confines of smoke compartments.

2. Obstructed Hallways

Wheel chairs, gurneys, carts can start to pile up in hallways, preventing impeding access to stairwells and exit doors. Make sure the hallways stay clear.

3. Improper Fire Rating on Doors

Painted over or missing fire rating labels is consistently one of the top violations. Ensuring that painters understand the importance of not covering door and frame labels can significantly reduce the potential for this violation. Where necessary, replace damaged doors with doors that have proper fire ratings. Regardless of the training provided to painters or specifications given to companies replacing doors, never close out a project without an inspection and commissioning process. ©2014 Allegion PLC

4. Broken Door Seals

Wear and tear will affect all doors eventually. A door that might close but not seal properly may allow smoke and fire to penetrate an opening much quicker.

5. Doors that Do Not Close Properly

A door that doesn't close is a door that can't be latched or prevent the spread of fire. Often, fixing a broken door is as simple as fixing a broken lever or a hinge adjustment.

6. Doors that Don't Self-close Properly

In many places, Life Safety Code requires the door to close and latch on its own without impediment. If doors are designed to close and latch without human intervention but fail to do so, the closer should be repaired or replaced immediately.

7. Missing or Unmarked Designated Fire Exits

Exits and exit egress pathways that are not clearly marked create a dangerous condition particularly in smoke filled hallways. In an emergency, occupants need to have clearly designated and identified egress routes.

Currently, The Joint Commission and Centers for Medicare & Medicaid Services are moving from using the 2000 Edition of Life Safety Code to the 2012 Edition. Make sure to check with your authority having jurisdiction (AHJ) to see what is mandated for your facility.

Source: Article Courtesy of Ingersoll Rand.

The information contained in this article is intended for general information purposes only and is based on information available as of the initial date of publication. No representation is made that the information or references are complete or remain current. This article is not a substitute for review of current applicable government regulations, industry standards, or other standards specific to your business and/or activities and should not be construed as legal advice or opinion. Readers with specific questions should refer to the applicable standards or consult with an attorney.

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