HospitalInspections.org

Based on surveyor observation, record review and staff interview it has been determined that the hospital failed to ensure the safety of all patients, staff, and visitors in accordance with 42 CFR 482.41 Conditions of Participation: Physical Environment related to maintaining compliance with the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC).

Please refer to the following:

-A-0701-Failure to develop and maintain the physical plant in such a manner that the safety and well-being of patients are assured.

-Form CMS-2567 Life Safety Code report.

Based on surveyor observation and staff interview, it has been determined that the hospital failed to ensure that the physical condition of the hospital was maintained in a manner to ensure the safety and well-being of the patients, staff, and visitors related to fire safety.

Findings are as follows:

The Rhode Island Department of Health received notification from the State Fire Marshal's Chief Deputy informing of the hospital's non-compliance with Life Safety Code requirements. This notification prompted an investigation for regulatory compliance.

Review of an email sent from the Office of the State Fire Marshal's Chief Deputy to Employee ID# 2, dated 4/3/2025, revealed that the hospital had been informed that the exit access corridor and the associated exits from an exterior trailer used as the temporary site for sterile reprocessing, were not in compliance with the Life Safety Code requirements.

During a surveyor observation of the mobile unit located on hospital grounds housing the temporary site for sterile reprocessing, on 4/4/2025 at approximately 9:25 AM, the following concerns were identified in the presence of the Fire Marshal, Employee ID# 2, and Employee ID# 1:

-The secondary emergency exit from an exterior sterile reprocessing trailer was blocked by chain link fencing and parked cars.

-The primary entry/exit doorway of the exterior sterile reprocessing trailer led to an exit access corridor that was constructed with wood frame construction and lacked fire alarm or sprinkler protection.

During a surveyor interview with the Employee ID# 2, on 4/4/2025 at the time of the above-mentioned observation, he acknowledged the concerns listed above. He indicated that a fire watch detail had been established on 4/3/2025 and implemented on 4/4/2025 early morning, per the Fire Marshal's directive until the structure is removed.