Milwaukee County BHD: House of Horrors

The 100-page Wisconsin Division of Quality Assurance investigation of the Milwaukee County Behavioral Health Center is damning and infuriating.

The state inspectors found a host of violations ranging from inadequate fire safety to a filthy kitchen. Toss in lack of notification of guardians and improper handling of patient records and you’ve got a system-wide breakdown.

Technically, BHD failed in the areas of patient rights, medical records, pharmacy, infection control, maintenance, physical plant, and governing body.

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 fixesthose involving constructionare given a more generous timeline. The state is currently reviewing BHD’s plan to see if it’s adequate.

One private contractor at BHDA’Viands for food servicewas singled out for criticism, although CleanPower and the contractor responsible for storing medical records off-site were not properly monitored.

Here are the highlightserrr, lowlights:


Management and Administration:

“Based on observations, policy and procedure review, and staff interview, the hospital’s governing body failed to be effective in its responsibility for managing the hospital which affects all patients, staff and visitors.”

BHD responded: “On 6/7/10 the Division Administrator [John Chianelli] directed the appointment of a standing Environment of Care Committee to be chaired by the Division’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 6/25/10. The committee will meet at regular intervals and the chair shall directly report to the governing body.”

Physical Facilities:

The facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls. “Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor.”

Stairwells were used for storage, creating a fire hazard.

Failure to provide multiple light fixtures so that pathways would be lit and walkable if any fixture failed.

The facility did not provide a fire alarm system that was installed according to National Fire Protection Association standards.

The facility did not provide a sprinkler system that was installed according to NFPA standards.

The facility did not maintain the sprinkler system according to NFPA standards.

The smell of sewer gas was coming from floor/shower drains.

Contracted Services:

“The hospital failed to oversee and manage two of two contracted services to ensure these contracted services were appropriate and functioned effectively. These failed practices affects all hospital patients, staff and visitors.”

“The hospital’s Infection Control Practitioner S does not provide oversight or guidance in the dietary departments, and acknowledged the need for infection control oversight.”

“The hospital contracts with an off-site storage location to maintain patient medical records when the hospital can no longer keep them on site. 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.”

Patient Care:

“This hospital does not ensure that patients’ physical safety is maintained by failing to remove potential obstacles and hazardous materials that could be used for self-injury on 4 of the 5 inpatient units.”

“This hospital did not ensure that required information was included on all medical records forms, such as proper authentication of orders and forms (5 out of 30 medical records reviewed[redacted]), documentation of parent/guardian notification (1 out of 15 medical records out of a total of 30-[redacted]), and inclusion of involuntary medications (2 out of 20 medical records out of a total of 30[redacted]). In 3 out of 30 medical records ([redacted]) discharge order forms were prematurely signed.”

“The hospital failed to obtain proper informed consent from a legal guardian in 1 out of 3 [redacted] adult patients with guardians.”

Some medications were improperly stored and not dated.

Infection Control:

“The hospital failed to provide a sanitary environment to avoid the transmission of infections and communicable diseases and failed to have an effective and active infection control program for the prevention, surveillance, control, investigation and guidance to all areas/services in the hospital whether the services were provided directly by hospital staff or under contract. This failed practice would affect all patients, staff and visitors.”

The infection control specialist told the investigators that the hospital had never asked him/her to provide inspection control expertise, guidance or surveillance to any other department aside from the in-patient units, including kitchen, housekeeping, laundry, pharmacy, and central supply.

“Environmental tours reflect poor housekeeping, uncleanable work surfaces, mold and unsanitary kitchen and laundry areas. This deficiency occurred in all of the 36 smoke compartments, all inpatient units, and would affect all patients in the facility on the day of the survey, as well as staff and visitors.”

On-Site Kitchen:

A’Viands [private food service vendor] representative “confirmed the dish room was not on a cleaning schedule.”

That A’Viands representative “was unaware the contracted service was responsible for maintaining the cleaning of the kitchen area.”

That A’Viands representative “confirmed the dry food storage room was not on a cleaning schedule and should not be used for all-purpose storage.”

The broken garbage disposal “had old food remaining in it and smelled foul. Fruit flies were noted throughout the dishwashing area.”

"No separation of clean and dirty for the following: the routing of dishes, placement of clean carts next to garbage cans, transport carts for clean trays had dirty trays on it."

“All Camro carts that are used to prepare and transport food were dirty inside, noting old food debris on the interior doors, the interior sides and at the bottom.”