Patient Room Numbering System

Q: In our hospital the nurses found the architectural room numbers too confusing and wanted all patient care rooms to be in numerical order, so about 15 years ago they inserted paper numbers under the placards (for example one room will be C159 with an insert of 110). What are the codes for room numbers and labeling? Where can I find references?

A: The Life Safety Code does not provide much direction on room numbering. But NFPA 99-2012 section 5.1.11.2.1 does say medical gas shutoff valves must be identified (i.e. labeled) with the room that they serve. So, make sure the room numbers on the door match up with the room numbers on the labels for the medical gas shutoff valves.

If you are saying each room has two different numbering systems marked on the door, then that is certainly confusing to an outsider and would likely lead to a finding by a surveyor.

Other than that, I suggest you check with your state or local AHJs to determine if they have any requirements concerning this issue.

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UPDATE: After this posting was published, I received the following reply from a reader:

In addition to the Medical Gas references, just a quick friendly comment to supplement the post regarding Patient Room Numbering, at least in the State of Florida: NFPA 99-2012 section 7.3.3.1 and 7.4.3.1 Nurse Call Systems; and FGI Guidelines 2.1-8.3.7 Call Systems, all address the issue of communication of patient staff calls for assistance and information, medical device alarms, and patient safety and security alarms. The code requires annunciation of each call in several locations including the nursing station of the associated nursing unit. If the staff must learn alternative room numbers that are not annunciated over the system, this will most definitely generate a survey deficiency that will need to be corrected immediately. It is best practice for both the design professionals preparing the original plans, the life safety officer and/or consultant surveying the facility, and the AHJ reviewing plans and/or conducting regular surveys to require that the physical wayfinding room/bed location numbers posted agree with the Nurse Call System annunciation. 

While I agree with the reader’s comment, it is important to understand that any finding by a surveyor would be based on an interpretation of NFPA 99-2012, section 7.3.3.1, as there is no specific standard that requires the nurse call annunciation to agree with the actual room numbers. Authorities are permitted to make this interpretation based on section 4.6.1.1 of the 2012 Life Safety Code.

Sprinklers in Patient Room Lockers

Q: Are sprinklers required in patient room lockers for existing facilities?

A: No… Section 8.1.1 (7) of NFPA 13-2010 says furniture not intended for occupancy is not required to be sprinklered.

Patient Room Decorations

Q: Where does “Homelike Environment” end and fire safety begin? We have a resident who likes to push-pin everything she makes in activities to her wall. On a recent Life/Safety visit, the surveyor noted that she had “too much stuff” on her walls and that it was a “fire hazard”. We are supposed to encourage “homelike” and “Individualized Care”, then we are told that we have to tell the resident that they cannot decorate their “home” as they desire. I know there has to be a balance, but the items do not impede entrance nor egress to the room and, while there are a lot of items, high and low, they are not on top of one another nor sticking out more than 3 or 4 inches from the wall. One might consider them to be “cluttered”, however, they are not on the floor. Also, he said that everything from pictures to wreaths to whatever has to be “flame retardant”. Are we to spray everything that a family brings in from home?

A: By the sound of your comments, it appears to me that you are referring to a nursing home environment. I am very empathetic to your problem as I understand that CMS state agencies want you to create a “home-like” environment for long-term care patients, but yet, you are required to comply with the 2012 edition of the Life Safety Code.

However, there is some relief available to you on this subject. Since CMS adopted the 2012 edition of the Life Safety Code effective July 5, 2016, section 19.7.5.6 changes how decorations may be displayed in the patient’s room:

  • Combustible decorations are permitted to be attached to walls, ceiling and non-fire rated doors as long as the decorations do not interfere with the operation of the doors
  • Combustible decorations may not exceed 20 percent of the wall, door and ceiling areas inside any room or space of a smoke compartment that is not fully protected by sprinklers
  • Combustible decorations may not exceed 30 percent of the wall, door and ceiling areas inside any room or space of a smoke compartment that is fully protected by sprinklers
  • Combustible decorations may not exceed 50 percent of the wall, door and ceiling areas inside patient sleeping rooms having a capacity of no more than 4 patients, in a smoke compartment that is fully protected by sprinklers

I don’t know if the decorations covering the walls that the surveyor saw were within the above limitations, but I would think your organization could calculate the square footage of the decorations and ensure it stays within the limits.

Patient Sleeping Room Locks

Q: Are locks permitted on patient room doors? Where can I locate the NFPA requirements for adding new hardware to patient room doors?

A: Section 19.2.2.2.2 of the 2012 Life Safety Code says locks are not permitted on patient sleeping room doors. Then, an exception to this standard says key-locking devices that restrict access to the room from the corridor and that are operable only by staff from the corridor side shall be permitted. Such devices shall not restrict egress from the room. What this means is you can lock the door to a patient sleeping room as long as the person on the inside of the room can open the door and get out.

However, before you think about adding deadbolt locks to existing doors, section 7.2.1.5.10.2 of the same code says you cannot have more than one lock or latch to operate the door. This means a deadbolt lock that is separate from the door latch set is not permitted because it takes two actions to operate the door: 1) Unlock the lock, and; 2) Turn the latch set handle. What you can have is a lock that automatically unlocks the door when the latch set handle is turned. These are also called hotel suite locks, because they are common in hotels. There is a deadbolt that is integrated with the latch set, and a person may unlock the door by simply grasping the latch set handle and turning.

If by chance the door in question is a fire-rated door, according to NFPA 80 you are permitted to make minor changes to the door in order to install new hardware, provided the hardware is listed for use on a fire rated door assembly.

Windows in Patient Sleeping Rooms

Q: In the 2000 edition of the Life Safety Code, under section 18.3.8 “Special Protection Features -Outside Window or Door”, they have requirements for windows or doors to the outside in patient sleeping rooms. However, in the 2012 edition of LSC, under section 18.3.8 “Special Protection Features (Reserved)”, it does not list any requirements for windows or doors to the outside in patient sleeping rooms. Does this mean that outside windows or doors are no longer required?

A: You have touched on an issue that is not often discussed. Yes, you are correct: The 2000 LSC did require a window or door to the outside in patient sleeping rooms. Up until the 1994 edition, the LSC required those windows and doors to operate, to allow venting during a fire emergency. In the 1994 edition, the LSC changed to stop requiring the windows to operate, but the requirement for the windows or doors remained. In the 2009 edition, the LSC deleted the requirement for windows or doors to the outside in patient sleeping rooms all-together, because the technical committee feels the total concept approach in section 18/19.1.1.3 covers the issue of evacuation, and no longer requires such an opening.

However… that does not mean you can design new hospitals without windows in patient sleeping rooms. Many local building codes, and state agencies with authority over hospital construction, still require windows in patient sleeping rooms in hospitals. There is a psychological need for the patient to see the outside light of day in the recovery process. The problem is, the LSC does not deal in the psychological needs of patients… at least not on this issue.

I also reviewed the Final Rule that CMS issued last May when they adopted the new 2012 LSC. Sometimes, CMS will retain a requirement in an older version of the LSC even though the newer version no longer requires it. In this case though, CMS did not say anything about keeping the requirement for windows in patient sleeping rooms.

But I suggest you check with your state and local authorities to determine if they have any regulations on this issue.

Temporary Storage in Patient Rooms

Q: We have a short-term project where we need to find some space to store equipment until they are installed. The equipment is electronic and needs to remain in their cardboard boxes until it is installed. We think we need to store these items for 6 – 8 weeks. Can we use patient rooms that are not in service as temporary storage areas?

A: Your question is more like “Can we violate the Life Safety Code (LSC) for a short period of time?” In some situations you are permitted to violate the LSC. Section 4.6.10.1 of the 2000 edition of the LSC says you are permitted to occupy the building during construction, repair, alterations, or additions where alternative life safety measures (aka Interim Life Safety Measures), which are acceptable to the authority having jurisdiction, are in place. If the equipment that you wish to store in the out-of-service patient rooms qualifies as construction, repair, alterations or additions, then I would say you have a legitimate position, as long as you implement alternative life safety measures. The measures that you implement should be in accordance with your policies.  However, out-of-service patient rooms cannot be used for storage of combustibles (in this situation, the cardboard boxes would be considered combustible) that is not associated with construction, repair, alteration or additions. The reason is most patient rooms are not constructed to meet the requirements for hazardous storage rooms. Make sure you perform the alternative measures and document each inspection.