A state and federal investigation uncovered inconsistent staffing levels resulting in an unsafe environment for patients at Wheaton Franciscan Healthcare-All Saints inpatient mental health unit.
Acting on several complaints, surveyors from the State Division of Quality Assurance (DQA), and the Center for Medicare and Medicaid Services (CMMS) conducted an unannounced visit in May to the children and adolescent unit, and adult inpatient mental health units at 1320 Wisconsin Avenue.
The investigation by DQA and CMMS uncovered instances of uncontrollable adolescents being placed in the same unit as sex offenders, a number of sexual assaults between patients, discriminatory admission practices, and nurses being told by management to falsify safety checks by saying the checks were conducted when they were not.
Wheaton Fixing Known Issues When State Came In
Paul Mason, senior vice president and chief operating officer of Wheaton Franciscan Healthcare All Saints, acknowledged that the state identified “areas where improvement was needed.”
“We were already in the process of making improvements in our program when the survey was conducted,” he said. “A plan of correction was accepted by the DQA back in May, followed by a validation survey to ensure that the corrective actions have been taken.”
The state violations come on the heels of complaints filed with the Wisconsin Department of Workforce Development by several Wheaton Franciscan Healthcare staff – Tria Braun, Tina Tyler, Laurel Ostergaard, and Melissa Jozefowski – saying they were not being paid for lunches they worked and that their time cards were manipulated. The DWD noted that Wheaton did pay the employees for as much as two years back pay.
In the DWD complaint, which was filed in March, Braun alleged that Wheaton staffed the mental health unit at “critically low” levels, and staff felt that if they took a lunch “it would be a safety problem or impact patients’ negatively.”
Braun said she would not comment on the violations against Wheaton because she feared they would retaliate against her.
Staffing Issues Cause Unsafe Environment
The survey pointed out that staffing levels did not meet Wheaton’s internal policy, which normally exceeds state and federal regulations. The state did the survey on May 12 where they found reviewed staffing levels from 22 days and found that in all instances they had “inconsistent staffing patterns and that created safety issues for patients.”
“The hospital failed to ensure that patients were monitored and kept safe from contraband medications,” according to the Centers for Medicare and Medicaid Services. “The cumulative effect of these systemic patient rights problems has the potential to lead to unsafe procedures and an unsafe environment.”
The survey found:
- A patient was supposed to have been searched by two staff members and was only searched by one. She was found lethargic in her room in January after she was using heroin and pills that she had brought into the unit.
- A person was found crawling in the ceiling on Feb. 3 on the child/adolescent unit trying to escape.
- A man left the hospital’s mental health unit and wasn’t discovered missing until almost three hours later. The man’s spouse took him home and staff did not properly identify the man when they did a security round. This happened after a door was not checked and was left unsecured when it was typically kept locked.
- A nurse told the state surveyor that sexual assaults happen “a lot” at night on the psychiatric care unit and the unit does accept sex offenders, that nursing administrators are aware of the issues and incident reports are filed.
The mental health unit also kept a book listing 240 names of people who were not to be admitted, including children, adolescents, adults and geriatric patients because of “medical complexity, destruction of property, violence, acting out sexually or the ‘need for a state hospital.’”
While the book was used as a “guideline,” the survey found that it violated state law because patients are not supposed to be denied care based on their race, creed, national origin, ancestry, religion, sex, sexual orientation, marital status, age, newborn status, handicap or source of payment. Nurses told the state surveyor that the book was used to “screen patients who may be violent or injurious to others,” but another nurse told the surveyor that patients are supposed to be “re-evaluated in the ‘here and now.’”
Still, the state called for the destruction of the book, which was turned over to the hospital’s risk management department on May 26, according to the state survey.
Mason said admissions to the mental health unit are based on the condition of the patient and the ability of staff to care for the patient, but the patient’s admission is not based on a legal status such as convicted sex offender.
New Staffing Model In Place
Since the survey was conducted, all three inpatient mental health doctors — Ben Christenson, William Bjerregaard, and Ahmad Khan — have left Wheaton Franciscan Healthcare.
“We don’t believe the doctors left because of these issues,” Mason said. “To address the concern raised on the state survey summary that you reviewed, All Saints provided additional information validating our consistent compliance with all regulatory standards.”
The mental health unit has a new staffing model, which includes working with Medicus Firm, a company that provides temporary psychiatrists to staff the unit until the hospital is able to recruit full-time psychiatrists. Because of a national shortage of psychiatrists, the hospital expects the transition to take up to nine to 12 months, Mason said.
However, there have been times when the inpatient unit has restricted the number of beds to give staff and new physicians time to work with patients.
“Our goal is to always provide safe and high quality care to our patients and we do this in part by ensuring adequate time and resources are being dedicated to each patient,” Mason said. “Please know that it is not our intent to close our inpatient programs. We remain committed to serving the members of our community who need mental health and addiction treatment and intend to do this through high quality, compassionate care.”