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More Troubles at Milwaukee County Mental Health Complex

State finds inadequate patient treatment, record privacy, sanitary conditions and safety

Jun. 23, 2010
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The 100-plus-page Wisconsin Division of Quality Assurance investigation of the Milwaukee County Behavioral Health Center reveals a systemwide failure to ensure the safety and well-being of patients in the county’s care.

According to the state, which sent inspectors to Milwaukee in May, the county’s Behavioral Health Division (BHD) failed in the areas of patient rights, medical records, pharmacy, infection control, maintenance, physical plant and governing body, meaning that the administration of the hospital hasn’t fulfilled its responsibilities.

BHD has submitted a Corrective Action Plan to the state and has promised to make most of its fixes by June 25, 45 days after the inspection. Other corrections—those involving construction, for example—are given a more generous timeline.

“Submission of this Plan of Correction is not an admission that a deficiency exists or that one was correctly cited,” the county wrote in response.

Part of the plan is the appointment of a standing Environment of Care Committee to be chaired by BHD’s Assistant Administrator-Environment of Care Compliance. The Environment of Care Committee members will include the infection control practitioner and representatives from dietary, engineering, maintenance and cleaning operations. The committee will begin meeting by June 25, the 45-day deadline, and will meet regularly.

The state is currently reviewing BHD’s plan to see if it’s adequate, said Seth Boffeli, a spokesman for the state Department of Health Services’ Division of Quality Assurance (DQA).

The Milwaukee County BHD is not accredited with the national organization The Joint Commission, which requires inspections once every three years.

BHD is inspected by the state once every four and a half years in a recertification review on behalf of the Centers for Medicare and Medicaid Services, and also when complaints have been made about the facility. Boffeli said the state has made 17 complaint-driven investigations in the past five years; 11 of those complaints were substantiated.

Systemwide Failure

During the recertification inspection, the state turned up violations that affect all patients, workers and visitors, such as fire safety issues and inspection control failures. The main areas of concern include:

n Physical Facilities: The facility’s fire alarm system and sprinkler system were not up to national standards, and stairwells were used for storage. The smell of sewer gas was coming from floor shower drains.

The county reported that some problems have already been fixed, while other concerns need to be addressed in the long term.

  • Patient Care: BHD was cited for failing to care for its patients properly, such as not documenting a parent or guardian’s consent, not recording when involuntary medication (“chemical restraint”) is given, and not ensuring that medical records were complete upon discharge.

Administration has sent memos and held meetings to review these policies with staff, the county’s Corrective Action Plan notes.

  • Oversight and performance of private contractors: Inspectors also turned up problems in the oversight and performance of private contractors responsible for food service, housekeeping and off-site record storage.

A’Viands, which took over the food service last year, “was unaware the contracted service was responsible for maintaining the cleaning of the kitchen area.” An A’Viands representative “confirmed the dish room was not on a cleaning schedule.”

Some patient medical records are stored off-site. But the inspectors noted that “Medical Records Director B confirmed that employees of this contracted service have access to documents within a patient’s medical record. There is no documentation that this contract is reviewed to assure patient confidentiality.”

In its plan, the county said that it would, among other things, “maintain a record for each contractor, which includes, but is not limited to, infection control plans, copies of contracts and agreements, contract deliverable plans and audit data” and develop contractor score cards and reports.

  • Infection control: “The hospital failed to provide a sanitary environment to avoid the transmission of infections and communicable diseases,” the inspectors found, and administrators failed to give guidance to the hospital staff and private contractors.

“Environmental tours reflect poor housekeeping, uncleanable work surfaces, mold and unsanitary kitchen and laundry areas,” the report states.

The infection control specialist told the investigators that hospital administrators had never asked him/her to provide inspection control expertise, guidance or surveillance to any department aside from the in-patient units.

In its Corrective Action Plan, the county states that the infection control specialist “will have a written House-wide Surveillance Policy and Procedure developed” by June 25, and has been meeting with hospital departments and CleanPower—the contracted housekeeping vendor—to develop checklists and schedules.


BHD Administrator John Chianelli said BHD is a place to heal and be safe. “Patient safety is our highest priority and DHHS staff began looking at and addressing what needed to be improved immediately,” Chianelli said. “BHD will continue taking the necessary steps within the proposed time frame to comply with state and federal regulations.”

Candice Owley, president of the Wisconsin Federation of Nurses and Health Professionals, argued that proper management of staff resources and private contract workers is lacking, and staffing shortages from furloughs has made a tough situation even more difficult.

“The front-line workers at the County Behavioral Health complex struggle day and night to provide safe, quality care without enough staff and without support from administration,” Owley said. “[Milwaukee County Executive Scott] Walker's budget cuts, privatization actions and furloughs have been a disaster for the patients. The patients and employees deserve better and hopefully the state report will cause needed changes to be made.”

Richard Abelson, head of AFSCME Local 48, said he wasn’t surprised by the investigators’ findings.

“The residents’ living conditions are our working conditions,” Abelson said.

He said the performance of the private contractors was below the standards set by the county workers who had once held those jobs.

“There has been a failure to properly oversee these privatization efforts,” Abelson said, saying that Chianelli “has given the privateers a free hand.”


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