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.


Q: Are there any requirements regarding outer hospital windows to have curtains or blinds? Some seem to think that they are required in case of severe weather as curtains are closed to prevent flying glass. I can’t seem to find anything in the Joint Commission or NFPA standards.

A: No, I’ve never seen or heard of any codes or standards that require them. However, without them, the patient may be at risk of flying glass as you suggested, and that risk would need to be assessed and documented. Therefore, a surveyor may expect to see curtains or blinds, and if there are none, the surveyor has the right to inquire if you have conducted a risk assessment. If no risk assessment is available to review, they then have the option to cite you if they feel it is significant. Check with your state and local authorities to determine if they have any regulations that would require them.

Privacy Curtains or Screens?

Q: The health care facility where I work needs additional privacy on the nursing floor from the rest of the building.  I would like to know if we could mount a ceiling track across the beginning of the nursing hallway, with a lightweight privacy curtain that can be drawn open or closed as needed; or place two decorative lightweight free-standing folding screens placed at the entrance to the nursing hallway.?

A: Assuming the nursing hallway that you refer to is an exit access corridor; then no, neither option that you suggest would comply with the LSC. Section of the 2000 LSC edition requires the corridor to be arranged to avoid any obstructions for the convenient removal of non-ambulatory patients. That means nothing may be placed in the corridor that could obstruct access, such as the screen. A curtain hanging down from the ceiling would not be permitted according to section, which could conceal the path to the exit. However, permanently installed side-hinged swinging privacy doors would be permitted and are often used in situations like the one that you described. The new barrier for the doors would not have to extend to the deck above and would be permitted to terminate at the ceiling. The doors and frame would not be required to be fire rated, and would not have to have positive latching hardware. Any changes to the facility should be reviewed by your state and local authorities.

Open Mesh Curtains in Hospitals

Q: Our hospital is fully protected with automatic sprinklers. Our cubicle curtains have an open mesh at the top to prevent water discharged from a sprinkler head from being obstructed. Where is the code requirement that specifies what shape and size opening in the mesh is required in the curtains?

A: The answer is found in the Life Safety Code (LSC) section, which requires newly introduced cubicle curtains to comply with NFPA 13 Standard for the Installation of Sprinkler Systems (1999 edition). NFPA 13 requires the suspended curtain to be mounted a certain distance away from a sprinkler head based on the vertical distance the top of the curtain is to the sprinkler deflector. NFPA 13 does not have any exceptions that would allow the open mesh at the top of the curtains in lieu of the specified distance from the sprinkler. However, the annex section of requires the installation of the cubicle curtains to be coordinated with the installation of the sprinkler heads. One option the annex offers is for the curtain to have a ½ inch diagonal mesh (or a 70% open weave panel) at the top of the curtain and extend at least 18 inches below the sprinkler deflector. While the annex section is not an enforceable portion of the LSC, it does offer explanatory material for the authorities having jurisdiction (AHJ) to use in making their interpretations. In this case, Joint Commission has said they will accept the open mesh at the top of the curtains that complies with the requirements of the annex section. Ironically, later editions of NFPA 13 also included similar language in their annex section, as well.

I suggest you check with your local and state authorities to ensure they are OK with the open mesh option.