Strange Observations – Wall Mounted Signs

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

The discharge door for a stairwell opened out onto the 1st floor corridor, where egress was just down the corridor. (This is permitted by section 7.7.2 of the 2012 LSC, provided they met all of the other requirements).

As the picture indicates, when the stairwell door is fully opened, it sticks out into the corridor about half the width of the door. This can cause a momentary obstruction to people in the corridor when the door is open.

The facilities department thought it would be a good idea to warn people that the door may be a problem when open and created this sign on a swivel that warns people. To be sure, the sign does swing if anyone came into contact with it, but when it is in its normal position, it projected more than 4-inches into the corridor.

Even though the intentions for the sign were good, it does violate the maximum 4-inch corridor projection rule adopted by CMS, and therefore it was written up.

NFPA 99 Signs on Doors to Central Supply Systems

Q: According to Joint Commission standard EC.02.05.09 EP4 it is requiring this sign:
“Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening.” They are referencing NFPA 99 2012-5.1.3.1.1–5.1.3.1.7. Am I understanding correctly that if I have Oxygen, Medical Gas and Nitrous in the Medical Gas Storage Room that this is the correct sign I need?

A: I think you have this twisted a bit. Joint Commission’s standard EC.02.05.09, EP 4 (2018 CAMH) does not reference NFPA 99-2012 5.1.3.1.1 to 5.1.3.1.7. The EP 3 (located above EP 4) does, but EP 4 does not reference any NFPA standard or sub-section of NFPA 99.

So… where did Joint Commission get the information for EP 4? From NFPA 99-2012, section 5.1.3.1.8. But according to NFPA 99-2012, 5.1.3.1, sub-section 5.1.3.1.8 applies only to Central Supply Systems. This sign that 5.1.3.1.8 requires (Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening) is only required for Central Supply Systems, such as gas manifold rooms. It is not required on doors to storage rooms on units that contain less than 3,000 cubic feet of oxidizing gases.

Also, NFPA 99-2012, section 5.1.3.1.9 says locations containing Central Supply Systems or cylinders containing only oxygen or medical air shall have their doors labeled: “Medical Gases: NO Smoking or Open Flame”. Since this is a sub-section of 5.1.3.1, this requirement still only applies to Central Supply System locations, such as gas manifold rooms.

But the way Joint Commission’s EC.02.05.09, EP 4 is written, it does not really limit the signs to just Central Supply Systems….

My advice is to contact the accreditor for clarification.