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The top fire safety violations and how your facility can avoid them


July 1, 2019

Once again, The Joint Commission has released its top ten list of frequently cited standards in U.S. hospitals for 2018. Entire books have been written on ways to avoid them, but we figured we’d split them up. This month, we look at some of the top fire safety violations that The Joint Commission dings facilities for every year and try to make sense of how to do better next year.

LS.02.01.35—The hospital provides and maintains systems for extinguishing fires (88.9% noncompliance percentage)

What you should be doing: You need to make sure that if a fire starts in a hospital, it can be put out right away. This should go without saying. Yet every year, The Joint Commission finds hospitals that just don’t get the message.

Properly maintained fire protection equipment reduces the risk of loss, but there are many things that can make equipment noncompliant or even render it inoperable. When your equipment isn’t functioning properly, you put your building occupants at risk and increase the chances of being fined for a violation.

Simply having fire protection equipment in place at your facility isn’t enough. Fire code violations can include anything from improperly installed equipment to a missed service date. Periodic testing, inspection, and maintenance are crucial to guarantee the equipment will function properly in the event of an emergency. By conducting an assessment of your facility and watching for common fire code violations, you can improve your fire protection program and avoid unnecessary fines.

Common fire code violations include the following:

  • Painted sprinkler heads. Sprinkler heads aren’t meant to be pretty. They should not be painted or covered in any way. In addition to regular inspections, sprinkler systems must be inspected internally every five years to ensure they are free of corrosion and buildup that would restrict water flow.
  • Fire extinguishers that do not meet requirements for hazard type. Many fire hazards exist within a healthcare facility. However, different hazards require different types of extinguishers, and using the wrong extinguisher can sometimes make a fire worse. Make sure you have the appropriate extinguishers available based on the hazards present in your facility. In addition, you must make sure those extinguishers are fully functional. An extinguisher that has been tampered with or discharged is noncompliant.
  • No inspection paperwork. If no paperwork exists, did the inspection really take place? Work with a fire protection provider that offers complete and easy-to-understand inspection reports. This will help you keep track of all completed inspections and quickly reference them when needed.

LS.02.01.30—The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke (72.9%)

What you should be doing: A fire can cause a lot of damage and loss of life before it’s put out. You need to be able to let people know a fire is burning and give them a fighting chance to evacuate or shelter in place. Here are some of the most common reasons for these violations:

  • Failures in emergency lighting and exit signs. Occupational Safety and Health Administration (OSHA) 1910.37 and NFPA 101 require emergency lights and exit signs to be tested for 30 seconds monthly and 90 minutes annually, along with other important but easy-to-miss vitals a trained technician will know to check.
  • Improperly installed/nonfunctional alarm systems. Lives are at stake when a fire occurs, and an alarm system won’t do its job if it’s not properly maintained and tested regularly. NFPA 72 outlines required testing intervals for automatic fire alarm systems. Proper maintenance of a fire alarm system will greatly improve the chances that it will detect a fire, notify the building occupants, and alert first responders.
  • Burnt-out backup batteries. Backup batteries for alarm systems, emergency lighting, and exit signs are meant to ensure the equipment will work even if the electricity goes out. The NFPA requires that backup batteries be replaced in pairs, meaning even the manufacturer and date code must match. Compared to the rest of your fire protection equipment, backup batteries are cheap, so don’t skimp on this small but critical requirement.

LS.02.01.10—Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat (70.7%)

What you should be doing: Fire doors, we’re looking at you. In many ways, doors are simple devices. They’re considered the entry point into (or exit out of) rooms or buildings, and we take them for granted because we see and use them every day. But to those who deal with fire doors in hospitals, they are pieces of material requiring constant attention because their function is very simple: to save the lives of those who can’t save themselves by blocking the advance of fire and smoke.

Fire doors experience major wear and tear, and they often do not close and latch as they are supposed to. Every year, surveyors ding facilities that do not keep their doors maintained. Here’s what to do to stay on the surveyors’ good side:

  • Exceed what the standards say. Make your own standards (sort of). The most recent standards out there are from NFPA, who wants you to inspect annually. But there’s nothing that says you can’t establish a monthly program of inspections. That will both keep you ahead of any problems your facility has and will also impress the inspectors.
  • Make sure hardware works the way it was intended. This means actually testing the doors. The best safety officers walk through their facilities, open and close their doors, and make sure the doors close and latch when the fire alarm is tested.
  • Don’t forget rarely used doors. Make sure you are checking doors that aren’t used much, such as those that lead to rarely used suites and exterior doors. They may be rarely used, but they are still considered a route of egress.
  • Use the data you collect. Having the doors inspected is the minimum requirement of complying with the standard; using that information and data to your advantage is another piece of the puzzle. Use the information to figure out a schedule of inspections and maintenance that covers all your doors every year. Some facilities use computer software to keep track of problem doors and establish an inventory of repairs.
  • Talk to your carpenters. Before you or anyone else makes a change to any door, make sure the change won’t invalidate the door’s effectiveness against fire. A simple repair to a door or door jamb that creates a hole in the wall could render the door unacceptable as a fire barrier.
  • Pass ownership to those who break the doors. If environmental services keeps hitting the doors with carts and making them break, take the repair money out of their budget. You may suddenly find the doors more likely to stay in working order.

LS.02.01.20—The hospital maintains the integrity of the means of egress (67.4%)

What you should be doing: The “no exit” citations have been falling under The Joint Commission’s standard requiring hospitals to maintain the integrity of paths of egress (LS.02.01.20), and they are some of the most common violations every year.

When is a building exit not an exit? When it’s an exit that COULD be an exit, but really isn’t, and isn’t marked that way. Confused? Join the club. According to some experts, The Joint Commission is increasingly citing facilities that aren’t clearly putting signs up around doors that seem to be leading outside, but don’t.

  • Follow the leaders. Language used by the NFPA (Life Safety Code®, 2000 edition, reads “any door, passage, or stairway that is neither an exit nor a way of exit access and that is arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: ‘No Exit.’ ”

It sounds pretty straightforward, except that The Joint Commission apparently interprets the standard differently.

“Our friends in Chicago take a somewhat different position on this: Signs reading ‘No Exit’ are posted on any door, passage, or stairway that is neither an exit nor an access to an exit but may (my italics) be mistaken for an exit,’ ” says Steven MacArthur, a consultant with The Greeley Company in Danvers, Massachusetts. “If you ask me, there’s a fair distance between something that ‘may’ be mistaken for something else, like an exit and something that is likely to be mistaken for something else, like that very same exit.”

If the door, even indirectly, leads to the outdoors, consider it a path of egress. And make sure you have a sign that says so. The Joint Commission itself has said that a crowded corridor almost immediately leads to a violation. Inspectors are most likely to find objects placed in front of gas shutoffs and obstructed corridors that don’t allow a clear path for crash carts and a quick egress.


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