This regulation establishes fire loss prevention requirements for operating rooms, including periodic hazard evaluations, safety protocols for flammable germicides and antiseptics used during electrosurgery or laser procedures, preoperative time-out checklists, emergency procedures for OR fires and chemical spills, and staff training requirements. It references NFPA 99 (15.13) and is part of the CMS Life Safety Code survey process (Form CMS-2786R).
View official sourceK933 Features of Fire Protection – Fire Loss Prevention in Operating Rooms Periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established. When flammable germicides or antiseptics are employed during surgeries utilizing electrosurgery, cautery or lasers: packaging is non-flammable. applicators are in unit doses. Preoperative "time-out" is conducted prior the initiation of any surgical procedure to verify: o application site is dry prior to draping and use of surgical equipment. o pooling of solution has not occurred or has been corrected. o solution-soaked materials have been removed from the OR prior to draping and use of surgical devices. o policies and procedures are established outlining safety precautions related to the use of flammable germicide or antiseptic use. Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually. 15.13 (NFPA 99) Form CMS-2786R (07/2018) Page 48 Name of Facility 2012 LIFE SAFETY CODE PART III – RECOMMENDATION FOR WAIVER OF SPECIFI C LIFE SAF ETY CODE PROVISIONS For each item of the Life Safety Code recommended for waiver, list the survey report form item number and state the reason for the conclusion that: (a) the specific provisions of the code, if rigidly applied, would result in unreasonable hardship on the facility, and (b) the waiver of such unmet provisions will not adversely affect the health and safety of the patients. If additional space is required, attach additional sheet(s). PROVISION NUMBER(S) JUSTIFICATION