Courtyard

Q: Are there any life safety requirements concerning courtyards? We have an outdoor courtyard, surrounded on all sides by our building, with one door entering and exiting the area. As of now, the door remains locked with “Not An Exit” sign posted on it. Our management team would like to open the area to our visitors and came to me for LS concerns. From my perspective, we would need to look at Life Safety issues involving entering the area and look at adding an ‘Exit’ sign, inside the courtyard above the door that goes back into the hospital. Is there anything else that could pose a concern?

A: Beside the ‘Exit’ sign over the door from the courtyard, the courtyard would have to have constant illumination and the door from the courtyard to the indoors must be unlocked all the time.  The walking surface in the courtyard must be level with no abrupt changes in elevation greater than ¼ inch. Also, the “Not An Exit” sign is incorrect; the sign must read “NO EXIT” with the word “NO” 2 inches tall and the word “EXIT” 1 inch tall.

Signage Inside a Stairwell

Q: Can signage, other than that specifically required for inside a fire exit stairwell according to the LSC, be placed inside a fire exit stairwell?

A: Technically… no. According to section 7.1.3.2.3 of the 2012 LSC, it says the exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit, and if so designated, as an area of refuge. The Annex section of A.7.1.3.2.3 says the intent is the exit enclosure essentially be ‘sterile’ with respect to safety hazards.

But, it probably depends on the signage that you want to install in the exit enclosure. If the signage is truly tight to the wall surface and cannot interfere with exiting, then most surveyors would not say anything. But if the signage was in the same style as a hanging framed picture, then that would likely be cited, since it could interfere with exiting when someone brushed their shoulder against the framed picture and it falls off the wall and becomes a trip hazard, or if it was tight to the wall, the projection of the frame could be an interference as well.

But, the Annex section says the stairwell should be sterile… so a technical interpretation could say nothing can be in the stairwell. I have seen surveyors cite organizations for painted-on signs inside stairwell walls because it would cause people to stop and read them, which, in the opinion of the surveyor, would cause a back-up of people egressing and in turn would interfere with the use of the stairwell. That sounds like an extreme interpretation, but one that the surveyor is permitted to make.

Strange Observations – No ‘NO EXIT’ Sign

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

The door in the picture is to a courtyard where patients may go and enjoy the out-of-doors. The problem is, there is no ‘NO EXIT’ sign on the door, and in my opinion the door could be confused for an exit door.

The size and make-up of the ‘NO EXIT’ sign is very specific: The word “NO” must be 2-inches tall, and the word “EXIT” must be 1-inch tall. The word “NO” must be over the top of the word “EXIT”.

The reason the word “EXIT” is smaller than the word “NO” is the technical committee who wrote that portion of the Life Safety Code wanted people to read the word “NO” before they read the word “EXIT” while approaching the door.

Stairwell Signage

Q: With the new 2012 Life Safety Code adoption, my question is around the stairwell signage and 7.2.2.5.4.1. Hospitals are confused whether they have to replace all their signs to meet this new code requirement, or if they are grandfathered-in, and not have to comply. From what I interpret from the code, this would be for new stairwells only… is this correct?

A: No… This applies to all new enclosed stairs serving three stories or more, and all existing enclosed stairs serving five stories or more. There is no ‘Grandfathering’ in the Life Safety Code. There are requirements for new construction (Chapter 18) and there are requirements for existing conditions (Chapter 19), but other than that, there is no ‘Grandfathering’.

When new editions of the Life Safety Code are adopted, facilities must comply with new requirements that apply to existing conditions. Just because the building was compliant with the Life Safety Code at the time of original construction, does not permit the building a ‘pass’ on meeting new requirements that apply to existing conditions.

 

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.

Strange Observations – Conflicting Signage

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

What we have here is conflicting signage. The ‘Exit’ sign is saying “Hey, in an emergency come this way”. And the sign on the door says “Hey, don’t you dare enter”.

This is a conflict, and you cannot do anything to discourage anyone from using an exit.

The sign on the door has to go.

Exit Sign Monthly Inspections

Access Control Locks WEb 2Why is it that hospital facility managers are often surprised when surveyors ask to see the documentation that their exit signs were inspected on a monthly basis? Probably because no one has ever asked to see that documentation before. If that is the case, then the facility manager appears to be preparing for a triennial survey based on the results of the previous survey, which is a dangerous strategy to follow.

Section 7.10.9 of the 2000 Life Safety Code requires exit signs to be inspected monthly to ensure that the sign is in fact illuminated. This inspection can be done when the exit sign is illuminated by normal power or emergency power, but is not required to be checked under both sources of power. The inspection is to ensure the sign is illuminated, and the lamps inside the sign are not burned out, or the circuit is not de-energized.

Some facility managers try to argue this requirement away by saying their exit signs are LED and therefore the lamps never burn out. Well, LED lamps do burn out, but it just takes forever to do it. Unfortunately, the 2000 LSC does not have an exception to NOT inspect exit signs for illumination if they are equipped with LED lamps.

Perhaps facility managers are surprised when surveyors ask to see the exit sign inspection documents because The Joint Commission does not have a specific standard or EP that addresses the issue. That does not mean a Joint Commission surveyor cannot ask to see that documentation, though. But Joint Commission is not the only authority that hospitals have to be concerned with. How about CMS; or their state health departments; or the local fire inspector; or their insurance company? Surveyors for those entities could very well ask to see that documentation.

If you are not already inspecting your exit signs on a monthly basis for illumination, then I suggest you get started. Develop a monthly PM work order that has your maintenance staff or security staff looking at each exit sign, and recording whether or not it passed or failed its inspection.

Stairwell Identification Signs

A question came up recently as to the proper mounting of the stairwell identification signs that are required in stairwells of a certain height. The  wall-mounted stair identification signs are supposed to be mounted within the enclosure on each landing in stairs serving five or more stories. The mounting height is ‘approximately’ 5 feet above the floor landing, according to section 7.2.2.5.4 of the 2000 edition of the Life Safety Code. What does the word ‘approximately’ mean, in this situation? Is the 5 foot measured from the bottom, middle or top of the sign?

The NFPA 101 handbook (2000 edition) has a picture showing the 5 foot measurement is between the bottom of the sign and the floor. One could take this to mean the required 5 foot measurement is from the floor to the bottom of the sign, but that is not necessarily true. The handbook is just a commentary written by a NFPA staff individual, who is also a liaison between the Life Safety Code technical committees and the NFPA. While that person is very knowledgeable, it is still his (or her) opinion and is not considered part of the code.

The annex section of the Life Safety Code explains some of the rationale behind the decisions making up the code language. Unfortunately, the annex section for 7.2.2.5.4 does not discuss the 5 foot mounting height, but does say the sign is intended not only for individuals evacuating the building, but also for the fire department responders to understand critical information about the building during an emergency. The annex section also says the information on the sign can be divided up into two signs to eliminate information over-load.

So, when the Life Safety Code is not specific or clear as to its meaning, the interpretation is left up to those entities that enforce the code in your facility. Those entities are called the authorities having jurisdiction (AHJ) and for healthcare organizations, the national AHJs are the Centers for Medicare & Medicaid Services (CMS), Joint Commission, Healthcare Facilities Accreditation Program (HFAP), and Det Norske Veritas Healthcare (DNV). As far as I know, none of the above AHJs have publicly stated where the 5 foot measurement has to be, therefore since the official code language says ‘approximate’, then the 5 foot distance can be interpreted to be to either the top, the center or the bottom of the sign. You will be safe with any of those measurements. Keep in mind that the requirement for stairwell identification signs is found in chapter 7 of the Life Safety Code, which makes the signs required in any building with 5 or more stories, not just healthcare occupancies.

Always check with your local and state AHJs to determine if they have a more restrictive interpretation.

Confusing and Conflicting Signage: Part 2

Last July 5 I posted an article on conflicting and confusing signage, in regards to hospitals and nursing homes. The posting dealt with situations where I had observed (and took pictures) of signs that I thought presented a confusing situation, such as an ‘Exit’ sign over a door, with another sign that said ‘No Exit’. The conclusion of that posting was the AHJs will most likely cite you for having confusing and conflicting signage.

Then I recieved a reply from Robert Welch from the State of Kentucky Office of Inspector General asking where in the Life Safety Code would ‘confusing and conflicting signage’ be cited. Knowing that there is not  a specific reference in the 2000 edition of the Life Safety Code that says “Thou shalt not have conflicting signs…”, I came up with the following explanation:

Section 4.1.1 of the 2000 edition of the Life Safety Code (LSC) states the goal of the LSC is to provide an environment that is reasonably safe from fire and similar emergencies, and section 4.1.2 states another goal is to provide for reasonably safe emergency crowd movement. Having conflicting signs concerning exiting seems to me to be contrary to this goal. Section 4.2.1 requires a structure to be maintained to protect occupants who are not intimate with the initial fire development. Also, 4.5.3.3 requires the routes to the exits to be conspicuously indicated. Having conflicting signage in regards to exiting would not be obvious or easy to notice (i.e. conspicuous).

One could take this point further to section 18/19.1.1.3 which discusses the concept of the LSC and how it pertains to healthcare occupancies. It says the occupants shall be protected from fire by appropriate arrangement of facilities, adequate staffing, and development of operating and maintenance procedures composed of [among other things] design and construction. If the path of egress has a sign that says ‘Exit’ and another sign that says ‘Authorized Use Only’ then that (to say the least) is a poor design of the structure.

CMS weighs in on this with their Condition of Participation (CoP) §482.41 which requires the hospital to be maintained to ensure safety. Citing a CoP out of compliance may be a bit much on one conflicting sign, so standard §482.41(a) may be more appropriate. Joint Commission would cite conflicting signage under EC.02.01.01, EP 1; or EC.02.06.01, EP 1.

When conflicting signage presents a perceived risk to the safety of the staff and patients, then that is an offense that should be cited. The bottom line: hospitals should know better. The conflicting signs that you saw in my post of July 5 should have been caught by the facilities staff long before I came along and took a picture of them. Shame on them for not having an adequate Life Safety program whereby someone walked around and discovered those problems.