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Tag No.: E0013
Based on a record review and interview, the facility did not provide a consistent policy with regard to exit width requirements from the doorway to the back of the room to allow room for a gurney in the event of a medical emergency as referenced in Mendota Mental Health Institute Policy and Procedure Policy #1F.01 Title: Health and Safety Guidelines Item j. Room Accessibility.
Findings include:
1. On 11/16/2022 at 11:00 AM, a record review revealed that the Mendota Mental Health Institute Treatment and Rehabilitation Unit Procedures & Unit Rules ROOM CLEAN item 6. Stated:
There must be a 30-inch corridor into the room and nothing may be stored within 18 inches of the ceiling. (See MMHI Policies 1F.011 1.F.5.j and 2H.16 ILA.)
2. On 11/16/2022 at 11:00 AM, a record review revealed that the Mendota Mental Health Institute Policy and Procedure Policy #1F.01 Title: Health and Safety Guidelines references:
The Joint Commission, CAMH, Environment of Care Standards
National Fire Protection Association (NFPA) Life Safety Codes
DHS 124, Hospitals, Wisconsin Administrative Code
Madison Fire Department (MFD) - Fire Prevention Codes, City of Madison, Chapter 34
Wisconsin Department of Commerce
Fire Safety Item j. Room Accessibility
1) 30-inch exit width must be maintained from the doorway to the back of the room to allow room for a gurney in the event of a medical emergency.
3. On 11/16/2022 at 11:00 AM, a record review revealed that the Mendota Mental Health Institute Policy and Procedure Policy # 2H.16 Title: Patient Property and Clothing revealed a reference to section 51.61(1)(q) and (r), Wisconsin Statutes. II. Limits on property in room.
A. There must be a 30-inch clearance into the room.
According to Policy 1F.01, there needs to be two feet of clearance which must be maintained from the doorway to the back of the room and to the bed.
Two-foot, 24-inch width policy, 1F.01 conflicts with policy 2H.16 requiring a 30-inch width.
These findings were confirmed at the time of discovery by a concurrent interview with Staff A.