For those responsible for their hospital’s compliance with The Joint Commission’s Environment of Care Chapter, the most dreaded season may be the winter holidays. It is the season when the desire of well-meaning staff to celebrate and decorate often clashes with the rules and regulations facilities and safety professionals are responsible to uphold. 

Often, the safety officer must be “the Grinch” while walking the halls and units within the health care facility. 

NFPA 101®, Life Safety Code®, 2012 section states: “Combustible decorations shall be prohibited in any health care occupancy unless they are flame retardant. Exception: Combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.” 

How the facility applies this is based on hospital-specific policies and procedures, but some of the universal applications are:

  • Decorations may not be hung from the sprinkler heads or pipes or impede the flow of water from the sprinkler system. 
  • Ceiling tiles function as a smoke barrier; items should not be hung from the ceiling tiles or grid.
  • No decorations on fire doors or on doors in fire corridors.
  • Fire doors, hallway doors and patient room doors shall not be wrapped.
  • Decorations should not block views through windows and vision panels. 
  • No garland or tinsel.
  • A visual inspection of all electrical cords must take place prior to use to ensure no frayed ends or exposed wires.    
  • Do not place electrical cords or light strings such that they create a trip hazard. 
  • Electrical cords can never be daisy chained.

What is the balance between supporting the holidays that bring cheer to those receiving care while also ensuring that those decorations are not creating a hazard with severe consequences? 

The American Society for Health Care Engineering created a video to help staff understand these regulations and allow everyone to be a holiday-loving Grinch.