Shower Curtains in Behavioral Health Units

Q: Our facility uses full shower curtains mounted to tracks in the ceiling for all behavioral health units. These curtains and tracks are ‘break-away’ type for suicide prevention. Our administration does not want to use curtains with mesh at 18 inches below the sprinkler heads. I disagree and my contention is that the mesh is required unless there is a sprinkler head in the shower (which there is not). They counter that this has been in place through numerous state and Joint Commission inspections and has never been cited. Is there some exception or conflicting regulation of which I am unaware that permits this in behavioral health units? I know I have been cited on the acute care side for curtains without the mesh 18 inches below the sprinklers.

A: I have heard this argument made many times: “We have had numerous surveys and inspections and it has never been cited.” Just because it has never been cited does not mean it is not a LSC violation.

Surveyors and inspectors cannot see every deficiency during a survey; therefore, some deficiencies get over-looked. Also, ½” open spaces in the mesh curtain is a NFPA 13 Standard for the Installation of Sprinkler Systems, (1999 edition) requirement generated by the Life Safety Code (LSC). There are no distinctions between a behavioral health unit and an acute care unit for compliance with this NFPA 13 requirement. If a surveyor who is not familiar with the requirements of NFPA 13 (such as a nurse or an administrator) inspects the behavioral health unit and does not cite the curtain, then what does that mean? Nothing. It certainly does not mean the curtains are not a violation…. It just means the surveyor did not cite it.

Life Safety is Patient Safety, and not resolving a Life Safety Code deficiency is not meeting the minimum standards for Patient Safety. Most hospitals want to do more than the minimum requirements when it involves Patient Safety.

Shower Curtains

imagesTOY08WZHFor bathrooms and shower rooms that are protected with automatic sprinklers, do the shower curtains require the same open mesh at the top as privacy curtains used in patients rooms? This was a question that I was recently asked, and my feeble mind immediately thought why would the NFPA codes and standards require sprinkler protection in a shower? What’s going to burn in there?

But a review of NFPA 13 (1999 edition) shows there are no exceptions for sprinkler protection in showers when the building is required to be fully protected with automatic sprinklers. (There is for small bathrooms in dwelling units, but that does not apply healthcare occupancies.) And I asked an associate of mine who knows more about sprinkler installations than I, who said showers can be a place that could be used to start a fire so there is a need to provide protection (who would have thought?).

Then I remembered there was an exception concerning shower curtains and after I looked that up, I realized that exception only applied to the requirement found in section 19.7.5.1 of the 2000 Life Safety Code that curtains needing to be flame resistant. So, that didn’t apply. So, after reviewing NFPA 13, I found that the answer would be… it depends. The shower curtains may need the ½ inch open mesh at the top 18 inches of the curtain if the top of the curtain is too close to the sprinkler head.

According to NFPA 13 (1999 edition), there are no exceptions for sprinkler protection in showers, so that means the showers need to have sprinkler protection. This can be achieved by having sprinklers mounted directly inside the showers, or it can be achieved by having sprinklers mounted on the outside of the showers and count on the spray pattern to cover the area of the shower. If the curtain does not have the open mesh at the top, then the top edge of the curtain needs to be a certain vertical distance below and a certain horizontal distance away from the sprinkler head, in accordance with Table 5-6.5.2.3.

So it is possible that if the top of the shower curtains are mounted far enough below the sprinkler and far enough away from the sprinkler, then the open mesh at the top of the curtain is not required. But if not, then the curtains would need to have the open mesh, as stipulated in the Appendix (Annex) section A-5-6.5.2.3.