Safety FAQ

How large may a trash receptacle (can) be if it is in a general patient/resident/client care area?
How many cans can be present in an uprotected area (out on the floor)?

A: A soiled linen or trash receptacle may not exceed 32 gallons in volume. There are two ways to think about how many individual receptacles may be present out on the floor:

No more than 0.5 gallons per square foot. A normal patient/resident/client room is 120 square feet, so the amount of trash should be no more than 60 gallons. Would two full 32-gallon trash cans be too much? Yes, by 4 gallons.

No more than 32 gallons may be located in a room of 64 square feet (8 by 8 feet). That is a lot of trash in a small room. So, are 50 gallon cans (barrels) out of the question? Permanently on the nursing floor; yes, but they may be used and stored in a Hazard Location when not attended.

May the janitorial staff push around a 200 gallon cart and pick up trash? Yes, if attended. When not attended, the 200 gallon cart is stored in the trash collection room, provided the trash collection room is a Hazard Location, so it is either protected with one-hour construction, or sprinkled and constructed to limit the transfer of smoke. There is no limit on the size of the containers or the amount of trash in this room.

Note: Requirement applicable to all facilities accredited by The Joint Commission.

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Exit Maps (Do we have enough exit maps?)

Refer to Emergency Evacuation Floor Plan Signage Workflow

Are exit maps required to be posted in LLUH buildings? If so, where and how many are needed?
A: Neither Joint Commission standards nor the NFPA 101 Life Safety Code require that exit maps be posted in hospitals or other health care occupancies. However Title 19 of the CCR or California Code of Regulations (enforceable by state surveyors) requires that “A floor plan providing emergency procedures information shall be posted at every stairway landing, at every elevator landing, and immediately inside all public entrances to the building. The information shall be posted so that it describes the represented floor level and can be easily seen immediately upon entering the floor level or the building.” In the past, LLUH has installed many more exit/evacuation maps than are necessary. This can create challenges in keeping maps updated though due to construction or periods of renovation. For that reason EH&S has taken on the responsibility of issuing and updating these plans when and where needed, which per the code is only in office buildings two or more stories in height, and Health care facilities regardless of how many floors there are. In conclusion, we would like to maintain maps at the areas required in the CCR, so that we reduce the possibility of having outdated maps discovered during surveys and inspections that will eventually trigger a negative finding by regulatory bodies. If your department feels the need to have one installed due to the complexity of their department’s floor plan, EH&S can provide them. Contact EH&S at 909-651-4018 for further information.

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Alcohol-based Hand Sanitizer Dispensers (Are hand sanitizer dispensers allowed in the hall?)

What are the "conditions" that have to be met to be able to insall ABHR dispensers in egress corridors?
A: According to the Joint Commission, location conditions and permissible volume specifications for gel ABHR dispensers to be installed in egress corridors are as follows:

• The corridor width is 6 feet or greater and dispensers are at least 4 feet apart.
• The dispensers are not installed over or directly adjacent to an ignition source such as an electrical outlet or switch. Adjacent is defined as being at least 6 inches from the center of the dispenser to an ignition source.
• In locations with carpeted floor coverings, dispensers installed directly over carpeted surfaces are permitted only in sprinkled smoke compartments.
• Each smoke compartment may contain a maximum aggregate of 10 gallons (37.8 liters) of ABHR gel in dispensers and a maximum of 5 gallons (18.9 liters) in storage.
• The maximum individual dispenser fluid capacity is 0.3 gallons (1.2 liters) for dispensers in rooms, corridors, and areas open to corridors.
• The maximum dispenser size for individual dispensers in areas designated as suites of rooms is 0.5 gallons (2.0 liters).

Note: Requirement applicable to all facilities accredited by The Joint Commission.

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Fire Extinguisher Training (FET)

How often must I attend Fire Extinguisher Training?
A: Every NEW employee should attend a Fire Extinguisher Training session within the first 90 days of employment. All employees are required to attend Fire Extinguisher Training at least once every three years thereafter.

See Regular Schedule & Registration for more info.

 

 

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A: Email the EH&S mailbox in the Outlook® Global Address List and request a Fire Extinguisher Training (FET) report. Please include your cost center in the email.

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A: On the Training page of this site.

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A: The Life Safety Code (NFPA 101, 2000 Edition) requires means of egress (exit halls) to be free of all obstruction or impediments. In existing healthcare facilities, it is required that the width of the aisles, corridors, and ramps be a minimum of 48” in patient care areas. In nonpatient care areas, a minimum width of 44” is required.

Also, if modifying existing buildings with exit corridors that exceed 8 feet, the exit corridors cannot be reduced to less then 8 feet per the Joint Commission (CAMH 2009, LS.02.01.20).

Any beds, gurneys, medical equipment, COWs, carts, wheeled bins, furniture, etc. should not be left unattended in the corridors.

For more info, see below requirements from the Life Safety Code (NFPA 101, 2000 Edition):

7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.”
19.2.3.4 Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by the following:
(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2) Where minimum corridor width is 6 ft (1830 mm), projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted for the installation of hand-rub dispensing units in accordance with 19.3.2.6.
(3) Where the minimum corridor width is 6 ft (1830 mm), projections shall be permitted in corridors, at both sides of the corridor, as follows:
(a) Each projection shall not exceed a depth of 6 in. (150 mm).
(b) Each projection shall not exceed a length of 36 in. (915 mm).
(c) Each projection shall be positioned not less than 40 in. (1015 mm) above the floor.
(d) Each projection shall have not less than 48 in. (1220 mm) horizontal separation from adjacent projections.
(4) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted.
19.2.3.5 The aisle, corridor, or ramp shall be arranged to avoid any obstructions to the convenient removal of nonambulatory persons carried on stretchers or on mattresses serving as stretchers.
19.2.3.6 The minimum clear width for doors in the means of egress from hospitals, nursing homes, limited care facilities, psychiatric hospital sleeping rooms, and diagnostic and treatment areas, such as x-ray, surgery, or physical therapy, shall be not less than 32 in. (810 mm) wide.

Note: Requirement applicable to all facilities providing healthcare.

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A: According to the NFPA 13 (1999 Edition), 18” of clear space must be maintained from the sprinkler head deflector to the top of storage, with the exception of a shelf that is installed on the wall and not directly under a sprinkler head. See below requirements for more info.

NFPA 13 (1999)
5-6.6 Clearance to Storage (Standard Pendent and Upright Spray Sprinklers). The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

A-5-6.6
The 18-in. (457-mm) dimension is not intended to limit the height of shelving on a wall or shelving against a wall in accordance with 5-6.6. Where shelving is installed on a wall and is not directly below sprinklers, the shelves, including storage thereon, can extend above the level of a plane located 18 in. (457 mm) below ceiling sprinkler deflectors. Shelving, and any storage thereon, directly below the sprinklers cannot extend above a plane located 18 in. (457 mm) below the ceiling sprinkler deflectors.

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A: A series of administrative actions required by the Joint Commission Comprehensive Accreditation Manual for Hospitals (CAMH) Life Safety Chapter (LS.01.02.01) to compensate temporarily for the hazards posed by construction activities or any other existing Life Safety Code© (LSC) deficiencies.

When are ILSM implemented?
A: ILSM are implemented by the Safety Office before a construction project begins or when a Life Safety Code© deficiency is identified.

How do ILSM affect you?
A: All employees should be familiar with the general principles of Interim Life Safety Measures and be able to recognize when their areas are being affected.

When ILSM are in effect in your area, the following items are a few of the measures that may be implemented:

1. The specific measures being implemented will be posted in, and adjacent to, the affected area. (See below example of ILSM poster)
2. You may receive additional training regarding these measures on how to compensate for the building deficiency in case of an emergency.
3. Additional fire extinguishers may be provided in areas where remodeling or construction is being done.
4. Additional Fire Drills may be conducted.
5. A fire watch may be posted.
6. If any primary exits are unavailable, alternative routes will be provided and they will be discussed in training sessions.

Note: ILSM may be implemented organization-wide, not just in healthcare facilities accredited by The Joint Commission

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A: NFPA 10 Standard for Portable Fire Extinguishers 2007 Edition Section 6.1.3.3.1 requires that “Fire extinguishers shall not be obstructed or obscured from view.” Also, Section 7.2.2 Procedures (2) requires that there be “No obstruction to access or visibility.”

Tip: If blocked fire extinguishers are a frequent problem in your area, a good way to discourage that is to place a red tape line on the floor in front of the extinguisher cabinet.

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A: The Incident Response Team is a small rapid response team made up of employees from key departments that are responsible for responding to Code Red Incidents and Drills. The responsibility of the team members is to assist the unit/department in response to the emergency according to their respective expertise.

Incident Responders should:

• Respond immediately to any “Code Red” or “Code Red Drill” announcements or pages;
• Have a fire extinguisher with them when they arrive at the scene of the incident;
• Assist the unit/department in executing the RACE Fire Plan.

Notification of the Incident Response Team is by fire group page and overhead page initiated by the Medical Center Control Center upon receiving an alarm or phone call reporting a fire emergency.

The Incident Response Team is composed of representatives from the following areas:

• Administration
• Clinical Engineering
• Engineering Services
• Environmental Services
• Nursing Administration/Supervisor
• Environmental Health & Safety
• Respiratory Care
• Security

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A: As soon as a work-related injury or illness occurs, follow the steps below:

1. Notify your supervisor, manager, or the person the department has designated to handle reporting.
2. Complete the two reporting forms:
   • DWC-1 (Employee’s Claim for Workers Compensation) (See your department head for your form)
   • 20-0032-A report of Accident/Illness Form (See your department head for your form)
3. Take the above forms and go to the Occupational Medicine Center located at:
   LLUHC Occupational Medicine Center (OMC)
   328 E. Commercial Rd, Suite 101
   San Bernardino, CA 92408
   Monday-Friday 7am to 5pm
   (909) 558-6222 or Ext. 66222
4. Report for treatment to the LLUMC Emergency Department for:
   • All emergencies (Severe trauma, unconsciousness, compound fractures or immobility due to severity of injury at any time)
   • After business hours for OMC 6pm to 7am and on weekends
5. Report for treatment for all needlesticks to the Advanced Urgent Care located at:
   Advanced Urgent Care
   25333 Barton Road
   Loma Linda, CA 92354
   Hours of operation – 7 days a week 6 a.m. to midnight
   After-hours – midnight to 6 a.m. – report to the Emergency Department (ED).

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Refer to Emergency Evacuation Floor Plan Signage Workflow

A: An evacuation plan is required by the Occupational Safety & Health Standards [CFR Title 29, 1910.38(a)] and is a written document that contains the information included in our new Area-Specific Evacuation Plans. Evacuation plans are intended to be understood and used by employees. Evacuation plans contain a variety of information including relocation points, which should be memorized by employees. The plan may also contain a drawing or a floor plan showing the relocation points; however, this is not required and would not look exactly like the posted evacuation maps, which are required.

Example Evacuation Floor Plan Attached to Department Evacuation Plan:

 

 

An evacuation map is required by the State Fire Marshal [CCR Title 19, § 3.09] to be posted in buildings 2 or more stories in height at every stairwell & elevator landing and all public entrances to the building. Evacuation maps are floor plans of the building describing the most direct evacuation routes, fire alarm audibles & visibles, fire alarm pull stations, and more; but they do not usually describe evacuation relocation points. Evacuation maps are intended to be understood and used by visitors to the building. The intent is for visitors to be able to obtain building-specific safety information before proceeding further into the building.

Example Posted Evacuation Map:

 

 

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A: The evacuation plan should be updated any time there is a change required in responsibilities or processes in the plan. The evacuation plan should be reviewed at least annually to ensure that the information in the plan is realistic and current. Any changes to be made should be submitted to EH&S as soon as possible using the “Create/Edit Area-Specific Evacuation Plans" link.

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A: The employer is responsible for training new employees according to OSHA standards; which, in our case, would be the Department Head or designee (e.g., Safety Coordinator or Educator). The training   that new employees receive at Orientation is more general in nature and does not share with them their department-specific evacuation plan – this should be handled by someone within the department.

Occupational Safety & Health Standards [CFR Title 29, 1910.38(f)] require the evacuation plan to be reviewed with each employee covered by the plan:

• When the plan is developed or the employee is assigned initially to a job;
• When the employee's responsibilities under the plan change; and

When the plan is changed

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A: First of all, the ring that normally provides a seal around the fire sprinkler head between the head and the ceiling is called an escutcheon. This little metal ring has an extremely important function: to resist fire & smoke from ascending into the space above the ceiling and thus preventing smoke and flames from spreading to other areas. This penetration is similar in importance to 2-3 inch holes in the wall. If one of these hard-to-pronounce, easy-to-fix metal rings comes done, save it and immediately report it to Engineering or Environmental Health & Safety. Escutcheons may seem small and unimportant; but regulatory agencies are constantly looking for them, so be sure to help us stay on top of our buildings’ fire safety!

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A: The frequency of conducting fire drills depends on the type of occupancy of the building. This table adapted from the 2007 California Fire Code (Table 405.2) should help you identify the frequency of drills in your building:

Fire drills must be conducted to comply with The Joint Commission, the local fire department, OSHA, the Centers for Medicare and Medicaid, and other regulatory agencies. If you have any further questions regarding fire drills, you may email us at EHS@llu.edu or call us at (909) 651-4019 or x14019.

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A: The Appliance Safety operational guideline (MC OG T-2) governs the acquisition and use of electrical appliances typically designed for household use.  Here are the general rules that apply to all appliances:

• Obtained in accordance with Policy Purchasing Process (G-1)
• Approved by a nationally recognized agency (e.g. Underwriters Laboratories (UL), Canadian Standards Association (CSA)
• Either equipped with a 3-prong plug or constructed to be double insulated which is evident by a box-in-a-box symbol on the device.
• Connected only to white normal power 115-volt AC outlets
• Prohibited in oxygen enriched atmospheres (e.g., tents, hoods), and kept 12 inches away from the expulsion site of oxygen
• Prohibited where there is a possibility of the electrical components getting wet.
• Fans must also meet the OSHA requirements for proper fan guard protection.
• Microwaves must also be restricted to use for food unless approved otherwise.
• Hair dryers must also have a GFCI power cord plug, meet UL requirements, be operated only be staff when used in ICU areas, and be stored away from patients after each use.
• Space heaters must also meet the following criteria:
  
  1. Be used only in non-patient areas (smoke compartments where patients are seen or treated).
  2. Plug directly into an outlet (not a surge protector or extension cord)
  3. Must have a tip over turn off switch.
  4. Be maintained at a distance of 3+ feet from combustibles or other hazards.
  5. Prohibited in any portion of a healthcare facility open to the corridor or wherein patients are examined or treated.
• Prior to use, the users department manager should inspect and approve it. 
• Multi-outlet adapters and extension cords are not allowed except in an emergency or on a temporary basis (See Extension Cord and Adapter Policy (MC T-10)).
• Prohibited appliances are those with open wire heating elements and open halogen light fixtures (e.g., some space heaters, toasters).
• Misuse of appliances can lead to disciplinary action and/or confiscation.

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Contact EH&S by …

• Email: EH&S Mailbox in the Outlook® Global Address List or email to: EHS@llu.edu;
• Phone: (909) 651-4019
• Fax: (909) 651-4171; or
• Intercampus Mailstop:
  Environmental Health & Safety Office
  LLUAHSC 101 Bldg

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