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.