About Hospital Safety Center  
Career Center  
Contact Us
       Free Resources
Hospital Safety Insider

Mac's Safety Space  
        News & Analysis
Healthcare Safety Leader  
Environment of Care Leader  
Forms and Checklists Library  




Time to remind staff about the fire dangers with decorations


October 19, 2019

by A.J. Plunkett (aplunkett@decisionhealth.com)

It’s October, so it’s about time to dust off the Scrooge costume for Halloween. Remind hospital staff about what they can and cannot do with decorations during the upcoming holidays.

If you have a written policy, this might be a good time to break it out and send it around. Maybe stop to say hello at a nursing station, with a smile and a copy of the policy in hand.

If you don’t already have a policy, consider these tips from Chris Burney, originally published in 2012 in Environment of Care Leader (a precursor to Healthcare Safety Leader). Now retired from healthcare management, Burney spent years in facilities management, including a stint as executive director of planning, design, and construction in the office of the vice chancellor of the University of Mississippi Medical Center in Jackson, Mississippi.

Every year, Burney would bring out what he calls his “Humbug Policy.” Yours should have elements of the same:

  • Prohibit any combustible decoration unless it’s fire retardant. If the decoration is fire retardant or resistant, it must say so on an attached label or on the packaging in which it came. Keep the box or labeling nearby—if a surveyor asks whether a decoration is flame retardant, you have to be able to prove it.
  • Allow exceptions as long as they meet Life Safety Code® (LSC) requirements. The LSC allows for decorations but sets limits on how many, what kind, and where (see a summary on p. xyxyx). For instance, never decorate doors or fire safety equipment.
  • Keep decorations separate from possible ignition sources. Don’t mix combustibles with those holiday lights.
  • Don’t allow open flames of any kind.
  • Prohibit flammable materials. That includes sprays such as artificial snow, or decorations like crepe paper in any quantity.
  • Don’t allow artificial trees unless they are labeled or otherwise documented to be flame retardant or flame resistant.
  • Make it clear that trees or large decorations can’t be placed in hallways or obstruct doors.
  • Have the hospital’s electrical or safety department approve lights or other electrical equipment for use. Electricals must be for indoor use only, and they must be UL or FM approved.
  • Don’t allow staff to hang decorations from the ceiling. They can obstruct safety signs. Also note that decorations CANNOT be strung from fire sprinkler heads.
  • Make it clear that all decorations must be removed by a certain date. And state that date.
  • Clarify that decorations cannot be stored in the department where they are used. The hospital’s facilities staff should oversee storage.

What does the NFPA say about decorations?

Here’s a summary of what the NFPA 2012-101 Life Safety Code® (LSC) says about combustible decorations.
They must:

  • Be flame retardant or treated with approved flame-retardant coating that is listed and labeled for application to the material to which it is applied.
  • Meet the requirements under NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
  • Exhibit a heat release rate not exceeding 100 kW, when tested in accordance with NFPA 289, Standard Method of Fire Test for Individual Fuel Packages, using the 20kW ignition source.

Decorations such as photographs, paintings, and other art must be attached directly to walls, ceiling, and non-fire-rated doors so as not to interfere with the operation or latching of the door; and when used inside a room or smoke compartment space, the decorations cannot take up more than:

  • 20% of space in an area not protected throughout by an approved sprinkler system, or
  • 30% of space in an area protected by a supervised automatic sprinkler system, or
  • 50% of space inside patient sleeping rooms with no more than four persons that is protected by an approved, supervised automatic sprinkler system. And any of those sprinkler systems have to be in accordance with Section 9.7 of the LSC.

An explanatory note in the LSC Annex says that the “percentage of decorations should be measured against the area of any wall or ceiling, not the aggregate total of walls, ceilings, and doors. The door is considered part of the wall. The decorations must be located such that they do not interfere with the operation of any door, sprinkler, smoke detector, or any other life safety equipment. Other art might include hanging objects or three-dimensional items.”

Decorations such as photographs and paintings must be in such limited quantities that hazard of fire development or spread is not present.

For the exact language, consult the NFPA codes themselves.

Subscribe Now!
Sign up for our free e-newsletter
About Us | Terms of Use | Privacy Statement | Contact Us
Copyright © 2019. Hospital Safety Center.