Decorations or Communications?

Combustible decorations on bulletin board Web 2The 2000 Life Safety Code, section 18/19.7.5.4 is pretty clear when it states combustible decorations are not permitted in healthcare occupancies unless they are flame-retardant. Flame-retardant decorations can be purchased, but you need to maintain some sort of documentation that the decorations are flame retardant, such as the original packaging. Then it can be presumed that the decorations are acceptable.

At the hospital where I used to work, the maintenance supervisor purchased huge Christmas wreaths for decorating the main lobby. They were made of plastic materials and fortunately for him, he retained the documentation from the manufacturer that they were flame retardant. He actually stapled the documentation to the back of the wreath so it would always be available for review.

If you do not have any documentation that the decorations are flame retardant, then plastic, fabric, paper, and wood-based decorations could very well be cited as combustible decorations. Artificial flowers, whether they are plastic or fabric, can be considered to be combustible if there is no documentation that states otherwise.

Surveyors are not consistent in enforcing this issue. Some surveyors don’t pay much attention to this at all, while other surveyors only cite the more obvious combustible decorations, such as wreaths made from twigs, sticks and grape vines. However, I have seen some survey reports where the surveyors cited all plastic artificial flowers in the hospital.

But what about those bulletin boards frequently found on the nursing units? Many times these bulletin boards are layered with multiple pieces of combustible paper. Are these a violation of the LSC as well? Not necessarily. If the paper that is posted on the bulletin board is truly used for communication (i.e. memos, notices, and other communications), then it is not considered a decoration and therefore is not a violation of section 18/19.7.5.4.

However, many times the bulletin board will be decorated for a particular holiday, or a special event. In these situations, if the bulletin board is decorated with combustible material, then it has crossed the line from communication to decoration, and should be considered for a citation under section 18/19.7.5.4. This is always a judgment call by the surveyor, and the less there is for the surveyor to judge, the better off you will be.

Bulletin Boards in Corridors

Q: What is the requirement for bulletin boards in exit corridors? I heard from another hospital that bulletin boards greater than 4 square feet must be protected with glass. Is this true?

A: Not according to the 2000 edition of the LSC, but perhaps that hospital was referring to a local or state requirement. The 2000 edition of the LSC is rather quiet on the subject of bulletin boards, so authorities having jurisdiction (AHJ) that enforce NFPA codes and standards use their own interpretation for guidance. Some AHJs use section 19.7.5.4 as a guide to determine if there are sufficient quantities of combustibles that a hazard of a spread of fire is possible. I’ve seen other AHJs use section 17.7.4.3 which allows up to 20% of the wall surface with artwork and teaching materials, but that only applies to Day-Care Occupancies, and I don’t know how they make the jump to healthcare occupancies. Some AHJs use section 10.2.5 which allows up to 10% of the wall surface to be Class C where Class A and Class B finishes are required. But that provision was to allow wood trim around doors and windows or chair rail moldings. The bottom line: This is not an exact science. Since the LSC is not specific, it is up to the AHJs to interpret how to enforce it. Since the typical hospital has 5 or 6 different AHJs that enforce NFPA codes and standards, you will have to comply with the most restrictive interpretation, so I suggest you be conservative on this issue.

Bulletin Boards in Corridors

Q: What are the limitations to bulletin boards that have paper tacked to them, in exit corridors in a hospital? Do they have to be behind glass doors?

A: No, the bulletin boards don’t have to be behind glass or plastic doors, but it couldn’t hurt. The problem is the 2000 edition of the Life Safety Code (LSC) is very quiet concerning the issue of bulletin boards in corridors, and surveyors and inspectors are left to use whatever standard they believe is applicable. Some surveyors use section 10.2.5.3 of the 2006 edition of the LSC as a guide, which specifically addresses bulletin boards and says they should not exceed 20% of the aggregate total area of the wall where they are applied. But The Joint Commission and the Centers for Medicare and Medicaid Services have not adopted the 2006 edition, so that 20% rule is not enforceable. Another suggestion is to conduct an assessment for safety risk in regards to the bulletin boards that you do have. In the absence of written standards or codes on an issue, a risk assessment is always an acceptable solution to a perceived problem.

NOTE: Please refer to the October, 2010 posting for additional information on bulletin boards in the corridor.

Bulletin Boards in Corridors

Q: What, if any, are the limits on bulletin boards in a means of egress corridor? I have managers who want to place large quantities of paper on their bulletin boards in their corridors.

 A: There are limits in regards to the way the bulletin board is used. First, you have to determine if the bulletin board is used to display combustible decorations or just business papers. If it is used for decorations, then 18/19.7.5.4 applies, which says combustible decorations such as photographs and paintings in such limited quantities that a hazard of fire development is not present, are permitted. So, a bulletin board with paper decorations is a judgment call by the AHJ. Will it contribute to the spread of a fire? I suggest you go conservative on this, and request a ruling from your local fire marshal. On the other hand, if the bulletin board is used for business paper (memos, notices, etc.) and not for decorations, then the LSC is rather silent on the subject, when used in healthcare occupancies. I suggest you again consult with your local AHJ and request a ruling. In lieu of a direct LSC requirement, if the local AHJ permits the bulletin board to remain, then other AHJs should respect that.