Strange Observations – Part 43

Continuing in a series of strange things that I have seen while consulting at hospitals…

 

Where do you see public pay-phones in a hospital, anymore….?

In the behavioral health unit, that’s where. Or at least, that is where I saw this one.

The problem here is the phone and the wood booth projects more than 4-inches into the corridor, which is the maximum allowable amount by CMS.

Another problem that many of you readers pointed out that I forgot to mention, is the long cord on the telephone is a ligature risk.

Emergency Department Corridor Width

Q: What is the minimum acceptable clearance required in an Emergency Department corridor? Currently there is a crash cart stored for rapid accessibility and the distance directly in front of it is effectively reduced to slightly over 72-inches allowing enough room for a stretcher still to pass. The cart is on wheels and can be quickly easily rolled out of the way as might be needed.

A: Is the Emergency Department a suite of rooms? If yes, then you have nothing to worry about. There are no corridors inside a suite of rooms, even though what looks like a corridor is actually a communicating space. But you do have to maintain aisle width clearance and section 7.3.4.1.1 of the 2012 LSC says the minimum aisle width is 36-inches. So it looks like you have that covered with the 72-inches clearance.

However, if the Emergency Department is not a suite, then you must maintain corridor width requirements. But how wide is the corridor required to be in the Emergency Department? Well… that depends, based on the occupancy classification of the Emergency Department, and whether or not you have any inpatient sleeping rooms in the area. Section 18.2.3.4 (1) permits the clear width of a corridor to be 44-inches if the corridor is not intended for the housing, treatment or use of inpatients.

Now, before you say you don’t have any inpatients in the Emergency Department, remember that CMS has interpreted all Emergency Departments that provide observation beds must be healthcare occupancies, as they consider observation beds to be sleeping accommodations and therefore must meet inpatient requirements. So, if you have observation beds in the Emergency Department, then you must maintain corridor width of 8-feet.

 

But if you don’t have any observation beds in the Emergency Department, then 44-inches is your clear width requirement and it looks that you’ve made that.

Strange Observations – Part 21

Continuing in a series of strange things I have seen while consulting at hospitals…

This looks like an adjunct corridor, one that is not used by patients. It doesn’t have a finished ceiling, so that implies it is located in a support services area.

Just because the exit is not used very often is no reason you obstruct access to it.

I know storage space is a premium in hospitals, but this is just plain sad.

4-Inch Corridor Projection

Q: With the adoption of the new 2012 Life Safety Code by CMS, we had a discussion about projections from the corridor wall. Since the LSC only allows projections to be 4 inches, the question that came up was in regards to fire extinguishers mounted to the wall and not recessed as they project out from the wall about 7 inches. Will we be required to recess them or will they be allowed? The same question was raised about wall mounted telephones?

A: Actually, the 2012 LSC allows a 6-inch projection into the corridor [see 19.2.3.4(4)], but CMS’ Final Rule published May 4, 2016 said they will enforce the more restrictive 4-inch maximum projection into the corridor, based on the Americans with Disabilities Act (ADA). For all healthcare facilities that receive Medicare & Medicaid funds, they must comply with CMS’ exception to the 2012 LSC.

To answer your question, there are no exceptions to the 4-inch maximum projection rule. So, anything projecting more than 4 inches into the corridor, including fire extinguishers and telephones, would likely be cited by a surveyor or inspector.

I read a survey report just the other day where the surveyor cited the hospital for having an ABHR dispenser that projected into the corridor by 4 1/4 inches. So, AHJs are citing anything that projects more than 4-inches into the corridor, including fire extinguishers.

This may be a good opportunity to consider oval-shaped fire extinguishers that do not project more than 4 inches into the corridor. Take a look at these compliant fire extinguishers from Oval brand: http://ovalfireproducts.com/

 

Corridor Doors

Q: A deficiency was found by CMS on a recent survey that stated ‘staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings ready to close without impediments’. The finding was repeated three separate times as doors to a patient room could not be closed due to obstructions/impediments. In all three instances, the rooms were vacant, being used for storage, and had either a chair or waste basket blocking the door. Although we have regularly explained away this finding with Joint Commission surveyors as being an item we train our staff on (to move obstructions in patient room doorways in case of fire while closing all doors as directed by our fire plan) the CMS surveyor listed it as a deficiency and was not satisfied with our answer. Does this seem like a reasonable action to you? The rooms were vacant, and there were no patients in the rooms! Why would the CMS surveyor care if the doors closed or not? Do I have to attempt a zero-tolerance approach to this deficiency for all patient room doors (which would seem to be futile) or just enforce the regulation for vacant rooms only?

A: Corridor doors must close and latch at all times in the event of an emergency. Even corridor doors to vacant patient rooms used for storage.

I believe by what you have described, that the CMS surveyor was correct and justified in citing any corridor door that could not close. If there was an impediment blocking the door, such as a chair or a waste receptacle preventing the door from closing, then that is a deficiency. Here is the reason why… In an emergency, staff must quickly go through the unit and check rooms and close doors. If there is an impediment to quickly closing the doors, and the staff had to move a chair or a waste receptacle, then that slows down the process. The concept of the corridor door is to separate the room from smoke and fire in the corridor. If an impediment prevents the door from closing, then smoke and fire can enter the patient room and then the patient is in serious trouble.

You must enforce maintaining the corridor doors free from impediments to close them throughout your entire hospital, on units that are occupied and units that are not. I do not agree with your comment that seeking a zero-tolerance on this issue would seem futile. On the contrary, nurses have a very keen respect for patient safety, and if you explain keeping corridor doors free of impediments is patient safety, then I’m sure they will buy into that and keep the doors clear.

I’m a bit concerned that you are using vacant patient rooms for storage. Be VERY careful with that. If there are any combustible stored in those patient rooms, you have a big problem. The room would have to comply with section 43.7.1.2 (2) of the 2012 LSC on hazardous rooms. I would suggest you do not store any combustibles in vacant patient rooms.

Penetrations in Corridor Walls

Q: Our life safety drawings identify the corridors in our hospital as being smoke partitions. My question is do wall penetrations above the dropped ceiling need to be sealed with a fire caulk like products used in 1 and 2 hour walls?

A: According to the Life Safety Code, a hospital corridor wall is required to be meet two-different standards, based on whether or not the smoke compartment where the corridor is located is fully protected with sprinklers. If protected with sprinklers, then the corridor wall is permitted to be smoke resistant (not-fire-rated) and extend from the floor to the deck, or from the floor to the ceiling if the ceiling also resists the passage of smoke. Be aware, however, that where NFPA recognizes that a suspended grid and tile ceiling does resist the passage of smoke, the IBC does not.

The other corridor wall requirement is where the smoke compartment is not fully protected with sprinklers, then the corridor wall must be 30-minute fire-rated and extend from the floor to the deck above. There is no exception to terminate at the ceiling if the ceiling resists the passage of smoke. NFPA describes a 30-minute fire-rated wall as steel studs with one layer of gypsum board on one side.

Since you state your corridor walls are smoke partitions, then the question is, do they have to extend all the way to the deck or do they qualify to terminate at the ceiling provided the ceiling also resists the passage of smoke? Since these are smoke partitions and not fire-rated barriers, you would be permitted to use non-rated, non-combustible caulk to seal any penetration, in lieu of using fire-rated materials.

Suite Entrance Doors

Q: A hospital has 2 different suites with double egress entry doors and the Joint Commission surveyor noted that these doors are supposed to have latching hardware because they are “corridor doors,” but in my experience, cross-corridor doors are not typically required to have latching hardware.  Can you weigh in on this?

A: I agree totally with the surveyor. According to the LSC, suites are nothing more than rooms; albeit a large room with smaller rooms inside. Therefore, corridor entrance doors to suites must positively latch because corridor doors are required to latch according to 18/19.3.6.3.5, 2012 LSC.

The thing that throws people off is what looks like a corridor inside a suite is not a corridor; it is a communicating space. The requirements of a corridor do not apply inside a suite. But the designers often make this space 8 feet wide and for all intent and purposes people think it is a corridor. Then, the designer places double egress doors as entrances to the suite (which is good when you’re pushing patients in an out on beds) and the doors look like cross-corridor doors. They’re not; they are corridor doors.

The hospital has to make those doors positively latch or they have to change the designation from a suite to a corridor, which is not advisable.

Suite Entrance Doors

Q: We have a double egress, cross-corridor door which will enter a suite under a renovation project. The suite wall is also an existing smoke barrier wall, separating smoke compartments. However, we do not want an exit route through the suite, as this would be a code violation. The new layout will not cause a dead-end corridor and the suite will house less than 50 people. Is it allowable to replace the double egress door with a pair of out swinging doors?

A: As long as the new doors are not cross-corridor doors, I believe you can have a pair of single-egress doors as an entrance to the suite in a smoke compartment barrier. Under section 18.3.7.6 of the 2012 LSC, all new cross-corridor doors serving a smoke compartment barrier must be the double egress type. But from your description, it appears these new doors would not be cross-corridor doors, but would be corridor entrance doors to the suite.

These new doors would have to latch because they are corridor entrance doors to a suite, even though they serve a smoke compartment barrier.

Storage in a Corridor

Q: If I had a hallway (breezeway which connects two healthcare occupancies) which is greater than 8 feet wide (approximately 12ft) and beds and other equipment (usually broken chairs) are being stored on one side of the breezeway for more than 30 minutes, would this be allowed as long as the width is maintained at 8ft or greater?

A: Yes… it would be permitted according to section 18.2.3.4 of the 2012 Life Safety Code, provided the items stored in the corridor allow for a clear width of 8 feet in the corridor, and the items stored does not constitute a hazardous area. So, combustible items such as furniture would not be permitted if the total area of the stored furniture exceeds 50 square feet. Also, flammables would not be permitted to be stored in the corridor.

Another thing to look at is if the corridor could possibly be used by inpatients. If so, then the clear width must be maintained at 8 feet. But if there is no chance of inpatients using this connector corridor, then the required width would be 44 inches.

Corridor Projections

Q: I understand that with the adoption of the new 2012 Life Safety Code there is a change in corridor projections from 6 inches to 4 inches. Would this new code allow for a PPE cabinet to be recessed into the wall?

A: Yes… a PPE container that is recessed into the wall would be fine as long as the exposed portion does not project into the corridor more than what is permitted. When CMS published their Final Rule to adopt the 2012 Life Safety Code on May 4, 2016, they stated they will not recognize the NFPA Life Safety Code on corridor projections which allows a 6-inch projection. Instead, they are adhering to the ADA requirement of a maximum of 4-inches for corridor projections.