Christmas Decorations

I received the poem below from Jeff Clouse, Safety Officer at Baptist Health in Lexington, KY. He says it is his way of using humor with the staff of his hospital to stay compliant with the Life Safety Code during the holiday decorating season.

 

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‘Tis about a month before Christmas, and all through the halls,

I endeavor to walk, inspecting the walls.

Looking for wreaths made of twigs, and Santas of paper,

Don’t hide them from me, I will solve the caper.

 

 

Fake snow, pine cones and *gasp* open flames,

Get rid of these things; I will not play games!

Hang nothing from sprinklers, do not block the exits.

If you do, I’ll call Santa then for you…NO PRESENTS!

 

No real trees, no branches, no needles of pine,

Just please help me out, and save all the whine constructive input.

If these things spark up and begin to smoke,

It’ll be hard to get out, and that’s not a joke.

 

Now I’m almost done, but I need to mention,

Bring no cords here, not for extension.

Lights can be used, plugged right in the wall,

But not if they’re hot and stretch across the hall.

 

I’m not being mean; my heart’s not of stone,

But I just can’t leave those fire regulations alone!

And, hey, listen up, don’t be filled with woe,

Fire retardant decorations you can have; that’s the way to go!

 

Great people you are, be safe, that’s the trick,

Keep helping and healing our weary and sick.

I care, too; and that is the reason,

I want us to be safe, this entire holiday season!

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Do you use something unique to reinforce your decorations policy?

If so, send it to me and I’ll place it in the blog for all to see.

Merry Christmas!

Brad

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.

Combustible Decorations

Q: Our corporate office has informed us that we need to remove all artificial plants from the hospital if they do not have a fire rating label attached to the plant. Is an artificial plant considered to be a combustible decoration?

A: Well, it could be. It all depends on who is making the decision that an artificial plant is combustible. Section 19.7.5.4 of the 2000 edition of the Life Safety Code (LSC) says combustible decorations are prohibited in any health care occupancy unless they are flame-retardant. (There are exceptions to this rule, such as photographs or paintings in such limited quantities that a hazard of fire development is not present.) To understand this issue further, section 3.3.29 defines combustible as a material that will ignite and burn when used in the condition it is intended. But, this definition does not define how the test object is to be ignited. Is it by a spark, a lit match, or a butane torch? I presume if you took a torch to the artificial plant you could make it ignite. So, this brings us back to the question: Who is making the decision that an artificial plant is combustible? Since the typical hospital has 5 or 6 different authorities having jurisdiction (AHJs) who enforce the LSC, it only matters what the AHJ believes is combustible, not you or me. Without a label stating the artificial plant is flame-retardant, it may be a hard sell to convince an AHJ the plant is not combustible. In my experience, I have not seen a Joint Commission surveyor or a CMS inspector cite a hospital that has artificial plants as being combustible. It may have happened, but it is not a common finding. Now, decorations made from dried vegetation, such as grape-vine wreaths is an entirely different issue, and those definitely need to be removed.

Christmas Trees in Corridors…

Holiday season is upon us and hospital and nursing home facility managers begin the struggle with decorations that do not meet the Life Safety Code requirements. The most common deficiency with decorations are they are not flame retardant, as required by the Life Safety Code (LSC) according to section 19.7.5.4.

Take the issue with the Christmas tree in the picture to the left. Does it qualify as a flame retardant decoration? I don’t know, and I took the picture yesterday. It is an artificial tree, but I could not find any tag on the tree that offered an explanation that it was flame retardant. I asked the staff if the package it came in said it was flame retardant, and they said the original packaging was thrown away.

So, based on a lack of documentation, the tree does not qualify for section 19.7.5.4, and needs to be removed from the hospital. But there are other issues to consider as well. Section 19.7.5.4 is not limited to just Christmas trees, but all decorations regardless of the season. You may not be able to tell from the picture, but there are combustible items placed on the tree as decorations. Items such as plush stuff toys and paper ornaments. Also, staff had wrapped boxes as decorations and placed them under the tree, which contributes to the overall deficiency.

Then the issue of corridor clearance must be taken under consideration. The tree protrudes into the required width of the corridor. Had the tree qualified for 19.7.5.4 as a combustible decoration that is flame retardant, the tree in the picture is still a problem. It must be placed in an alcove or lobby  where it does not project into the required width of the corridor.

Facility managers and Safety Officers must deal with holiday decorations with tack and politeness, but also with firm decisiveness. The LSC is clear: combustible decoration (that are not flame retardant) are not permitted in healthcare occupancies. The authorities having jurisdiction will hold your organization accountable… so should you.