When he was one of The Joint Commission's life safety surveyors, Brad Keyes, CHSP, recalls walking into a hospital around the time of Halloween and seeing three bales of real hay and an actual scarecrow in the lobby.
"Hey, this is Halloween. This is fun and looks nice. Yeah—you're written up," Keyes told attendees at HCPro's "Life Safety Code Solutions for Hospitals" seminar last week in Boston. Keyes is a safety consultant with The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.
The Joint Commission and Life Safety Code ban combustible decorations unless they are flame-resistant, so the hay and scarecrow, while festive, were in fact a potential fire hazard that could result in a citation from surveyors.
That argument doesn't always sway staff members on units, however, who enjoy the chance to spruce up patient care areas with decorations for all the holidays that occur in the coming months.
With Halloween still a few weeks off, now is a good time for CEOs to sit down with safety officers, review decoration policies, and issue annual reminders about what types of decorations employees can properly display. Safety officers risk being viewed as Scrooges without CEOs backing them up on decoration enforcement.
"Most organizations have in a policy that a hazard surveillance or code compliant review shall be conducted," said Claude Baker, CFPS, fire and life safety officer and interim manager of safety and regulatory compliance at the University of Chicago Medical Center.
Key points in decoration policies, as noted by Baker, include the following:
- Verify all electrical components in decorations have an appropriate tag from a testing laboratory (e.g., Underwriters Laboratories) that is in place on the items in question. Note that some testing approvals don't cover all settings, such as items intended only for household use, Baker says.
- Don't allow decorations to obstruct exits or access to fire protection equipment (e.g., portable fire extinguishers).
- Ensure that staff members don't hang decorations from sprinkler heads and pipes, which would violate standards from The Joint Commission and National Fire Protection Association.
- Establish and enforce a timeframe for decoration displays so that workers know when the items must come down.
Dried wreaths and real Christmas trees are also risks to watch for. "Dried vegetation is combustible," Keyes said.
If a wreath box states the item is flame-resistant, it's OK to hang it, but keep the packaging or documentation in the package as back-up to prove the situation to surveyors, he said.