Storage in Patient Rooms

Q: Nursing staff has a tendency to stuff patient rooms that are not used as often with extra beds, furniture etc. Building does not have sprinklers on these patient floors so the concern is fuel load in a nonrated room. Is there a particular code I can cite to discourage this behavior?

A: Yes… Section 4.6.7 in the 2012 LSC says when you have a change in use (that’s what is happening… the patient room is not being used as a patient room anymore, but now is used as a storage room with combustible supplies), you need to comply with chapter 43. Section (2) says when existing healthcare occupancies are fully protected throughout with automatic sprinklers, when you have a change is use in a room that does not exceed 250 square feet, the result is the room does not have to meet new construction requirements but is permitted to meet existing conditions for hazardous rooms. This is significant as the room where the extra beds and furniture are placed would not have to meet the more restrictive new construction requirements for adding sprinklers and making the walls become 1-hour fire rated barriers, with a ¾ hour fire rated door assembly. The room would only have to be sprinklered and the walls and doors made to resist the passage of smoke and the door be self-closing. But this is only permitted if the entire building is protected with sprinklers, and you say it is not. Therefore, you have no choice; you must reconstruct the former patient room to be 1-hour fire rated with a ¾ hour fire rated door assembly and install sprinklers in the room. This could cost you $10,000 – $20,000 per room depending on the current arrangement of the facility. This is an example of staff changing the use of a room or area without checking with facilities to see if it is permitted. Your best bet would be to complete the sprinkler installation in your building.

Business Occupancy Soiled Utility Room

Q: Do business occupancy buildings with soiled utility rooms have to be one-hour fire-rated or just sprinkled if the building falls under a hospital license and will be inspected by State and CMS surveys?

A: It depends…. Is the soiled utility room used for general storage? In business occupancies, soiled utility rooms are not considered outright to be a hazardous area like they are in healthcare occupancies. However, many soiled utility rooms are also general storage rooms, and section 38/ of the 2012 Life Safety Code specifically says general storage rooms are considered hazardous areas and must be maintained in accordance with section 8.7. Section says the room needs to be either 1-hour fire rated or protected with sprinklers.

Whether or not the business occupancy falls under the hospital license is not a factor, regardless who inspects the building. The LSC is clear: If used for general storage, then the room is either sprinklered or 1-hour fire rated. If the room is not used for general storage, then there is no requirement. This is based on its occupancy; not its license.

Door to Compressed Gas Storage Rooms

Q: I have an oxygen/med gas storage room that is attached to the hospital, and can only gain access to the room by way of the exterior of building. Does the room have to have a fire-rated door assembly?

A: Well… that depends. If the storage room contains 3,000 cubic feet or more of compressed medical gases, and the room is located indoors, then the room must be constructed with 1-hour fire-rated construction and the door to the room is required to be 1-hour fire rated if new construction, and 3/4-hour rated if existing conditions. (See of NFPA 99-2012).

However, the intent of is to separate the compressed gas storage room from the rest of the facility by requiring 1-hour fire rated barriers, and if the door opening to the storage room opens into the facility, one could easily understand why a fire-rated door is required. However, if the door to the storage room opens to the outdoors (i.e. receiving dock) then one could make a point that the door is not required to be fire-rated, because there is no separation between the storage room and the rest of the facility at that point.

But the problem is, NFPA 99-2012 section does not say that and does not appear to have any exception for a door to the storage room that opens to the outdoors. I think a rational, smart, understanding surveyor would agree with that point and not cite you for not having a fire-rated door that opens to the outdoors.

But will you always have a rational, smart, and understanding surveyor?

Electrical Room Storage

Q: Are ladders allowed to be stored in electrical closets as long as the egress path is maintained and the 3ft clearance is applied? We had an inspector site 1910.303(g)(1)(ii) “Working space required by this standard may not be used for storage.” I referenced NFPA 70-2011 section 110.26 regarding the clearance which permits ladder storage but the surveyor ignored it. All our rooms are sprinklered and 1-hour fire rated.

A: The most restrictive requirement applies… You are correct that NFPA would permit storage of ladders in the electrical closet provided clearance to all electrical equipment is maintained. But this particular surveyor knew the OSHA requirements, and section 1910.303(g)(1)(ii) does prohibit storage in the electrical room.

It’s frustrating when you work hard to be in compliance with all NFPA codes and standards just to find out you are out of compliance with OSHA. If this was a CMS state agency survey or an accreditation survey, then I would say this finding is legitimate because of the 2012 LSC says any requirements that are essential for the safety of the building occupants and that are not specifically provided for in this LSC, shall be determined by the AHJ. The surveyor, who is the AHJ, apparently did determined that the OSHA standard 1910.303(g)(1)(ii) is essential for your safety, and therefore it applies.

I guess you will have to deal with it and find a new home for ladders. Also, better post signs inside your electrical room advising everyone to not store anything in the room.


NOTE: Since this article was posted, I have received numerous comments from people much smarter than I on OSHA requirements, stating they believe the surveyor was incorrect in his citation. According to the readers, OSHA says if the ladder is not in the working space then they think that it should be permitted.

Please use your own best judgement when considering any changes to storage in electrical rooms.

Cardboard Shipping Boxes

Q: We have a battle going on at our hospital regarding whether cardboard boxes can remain in a Pharmacy clean storage room. Some staff is saying the boxes must go. I thought that was only the case in an OR clean sterile room. IN this situation, the Pharmacy clean storage room is 1-hour fire rated. I guess this question will apply to all of our clean storage rooms in our hospital

A: You have two different standards at play, here. From a Life Safety Code point of view, you are compliant. Cardboard boxes are combustible, and having multiple cardboard boxes stored in a room requires the room to be maintained as a hazardous area. According to section of the 2012 Life Safety Code, the room would have to be 1-hour fire-rated or be sprinklered. You say the room is 1-hour fire-rated, so you are compliant with the Life Safety Code. There is no other Life Safety Code requirement that would prevent the storage of cardboard boxes in that room.

However, as I said, there is another standard at hand here. From an Infection Control point of view, cardboard boxes used for shipment presents many problems:

  • The boxes are dirty. They have been riding in the back of trucks for days, and they have been sitting on receiving docks which is a very transient environment. These boxes are not acceptable from an Infection Control consideration to be stored in a clean environment, let alone a sterile environment.
  • The boxes may contain insects or vermin. In some cases, you have no idea where these boxes came from. Insects can make a home in the cardboard boxes and then be shipped to your facility. Vermin have been known to hide in a cardboard box and also be transferred to other places.
  • If left on the floor, the boxes may become wet. A wet cardboard box becomes soggy and falls-apart and leaves a trail of contaminants that provides a place for mold or mildew to grow.

While there may not be a specific standard in the accreditation organization’s manual, or a CMS CoP standard that prohibits cardboard shipping boxes from being stored in a clean environment (i.e. pharmacy storage room), it is generally understood that most surveyors and inspectors will cite an organization for doing so. This is due to the perceived Infection Control issues described above. They would typically cite the facility under a general duty standard that requires the organization to maintain a safe environment for their patients and staff.

My advice is to remove the cardboard shipping containers from the facility at the point where you receive them (i.e. receiving dock) and discontinue storing any paper or cardboard container on a floor that has the potential to be wet. Discuss this issue with your Infection Control specialist. I’m sure they have an opinion on cardboard shipping boxes.

Correction to Yesterday’s Posting

Hello readers…

I did it again. I made a mistake in my answer to yesterday’s posting, which asked the question if signs are required on doors to storage rooms where there is less than 300 cubic feet of oxidizing gases stored. Initially I said yes, citing NFPA 99-2012, sections and which identifies the need for signs on doors to rooms that store oxidizing gases.

But, thanks to my good friend Marge McFarlane of Superior Performance, LLC, she spotted the error and sent me an email identifying it.

If you want the details… here is where I made my mistake: Sections and of NFPA 99-2012 are under the heading of 11.3 “Cylinder and Container Storage Requirements”. Only rooms that store 300 cubic feet of gas or more are required to meet requirements for storage rooms. Since sections and are sub-sections of 11.3, they only apply to conditions identified under 11.3.

So, I took sections and out of context and thought it applied to all rooms storing oxidizing gases, which was incorrect. It only applies to rooms storing oxidizing gases in quantities of 300 cubic feet or more.

I’ve corrected the posting so the mistake is gone, but if you read it and thought you need to add signs on all the doors where oxygen cylinders are stored, please understand the signs are only required if the room contains 300 cubic feet or more.

Sorry… I apologize to my readers. I hope you will forgive me. I strive to be accurate and not make mistakes, but as you can see, understanding and interpreting the standards can be tricky.

Thanks, Marge.

New Construction Supply Room

Q: Is it not the case that in new hospital construction, clean storage rooms between 51 and 100 square feet need only have a self-closing door meeting  Only clean storage rooms greater than 100 square feet need to be 1 hour rated.  Since not mentioned in table, I’m assuming storage rooms smaller than 50 square feet need not be rated nor have a self-closing door.  If all of that is correct, I have an engineer telling me that I need a smoke detector in a small storage room less than 50 square feet.  My hospital is fully sprinklered.

A: You are correct. Chapter 18 of the 2000 edition of the Life Safety Code for new construction does not require storage rooms containing combustible materials, that are larger than 50 square feet but not exceeding 100 square feet to be fire rated, but just be equipped with a self-closing device on the door. Storage rooms containing combustible materials less than 50 square feet are exempt from hazardous area requirements, so a self-closing device on the door would not be required. There is no Life Safety Code requirement for a smoke detector in this type or size of room. Perhaps the engineer is citing a different code or standard. I suggest you ask him/her to provide a code reference for review.

Door to Storage Room

Q: We have an Urgent Care facility that is classified as business occupancy. Do I need to lock the door to a storage room?

A: The Life Safety Code does not require a door to a storage room to be locked, in an occupancy classification used by healthcare providers, including business occupancy.

However, one of your authorities having jurisdiction (AHJ) may require the door to be locked, depending on the risk to safety for your patients and staff. If you are accredited by a national accreditation organization, they usually have a standard that requires the healthcare provider to assess the safety and security risks in the environment to your patients and staff. Depending on the contents and layout of the storage room, there may be a significant risk to unauthorized individuals (especially children and behavioral health patients). You may be required to assess the perceived risk in all areas, including the storage room and determine the best course of action to mitigate that risk. The easiest and safest decision may be to lock the door.

Also check with your state and local AHJs as well. They may have regulations that require the door to be locked.