HospitalInspections.org

Based on record review and interview the facility failed to ensure that their policy was followed by notifying the Department of Quality Assurance within 7 days of investigation findings, contacting police of investigation of inappropriate behavior by facility staff and ensuring that facility employees had retraining and "return to duty" plans in regards to allegations/behaviors prior to returning to work in 2 of 2 self report incidents reviewed.

Findings include:

The facility document titled "Investigating and Preventing Patient Abuse" #5982725 last revised 12/2020 was reviewed. This document revealed "II. Identifying, Reporting and Investigating Alleged Patient Mistreatment: v. Wisconsin Administrative Code DHS 13 requires that each facility report allegations of patient abuse, neglect or misappropriation if, after conducting a thorough internal investigation, there is information or other evidence to prove the incident happened; or to lead to the conclusion that a regulatory authority or investigating agency may be able to obtain evidence to prove that the incident occurred. These steps are taken at WMHI (Winnebago Mental Health Institute) to comply with such reporting requirements: 1. A report is made to DQA (Division of Quality Assurance) within seven calendar days of when the facility knew of the incident...b. Administrative investigation: This is initiated on the next regular business day following the reporting of the alleged incident. The steps in this investigation are as follows:..3. An initial decision as to whether the situation meets criteria for reporting to DQA. 4. An initial decision on whether to contact local law enforcement (NOTE: in all cases in which it is determined that DQA must be notified, law enforcement must also be notified);...c. Concluding the investigation: These steps will be initiated by the individuals specified:..iii. If the employee is to continue employment, the Department Director will determine any retraining or review needed by the employee, and will participate in the meeting with the employee and HR (Human Resources) Director to inform the employee of the return-to-duty plan. Training and review may be recommended regardless of whether discipline is given for a work rule violation, if the investigation reveals any area in which the employee's skills need improvement...v. If the employee is continuing employment, the direct supervisor will review the Performance Planning and Development expectations with the employee in accordance with DHS (Department of Health Services) policy 504, and make clear any expectations for improved performance. The supervisor will work with the HR Director to develop a plan for monitoring the employee's work and providing further training or guidance as necessary."

Examples of 7 day notification of DQA:

Psychiatric Care Technician G was accused on 3/3/2021 of passing notes, spending excessive time playing cards and making plans to meet with Patient #3 after discharge (inappropriate behavior) with an adolescent while working on Youth Services Unit (Sherman Hall). The facility displaced Psychiatric Care Technician G to an all male adult unit to work and instructed him/her to not return to Sherman Hall on 3/4/2021 and began an investigation into the allegations. On 3/11/2021 Psychiatric Care Technician G was placed on administrative leave. An "Investigatory Meeting" was scheduled with Psychiatric Care Technician G on 3/26/2021 to discuss investigation findings. The facility did not file a "self report" with DQA until 4/5/2021 (10 days later).

Psychiatric Care Technician F locked a patient in their room without following the established protocol to do so on 12/20/2020. An "Investigatory Meeting" was scheduled with Psychiatric Care Technician F on 1/8/2021 to discuss investigation findings. The facility did not file a "self report" with DQA until 3/3/2021.

An interview was conducted with Quality Management Nursing Supervisor H on 4/26/2021 at 12:00 PM who, when asked about the dates of the self reports to DQA stated "yes it was not within 7 days of us completing the investigations."

Examples of no notification of police:

Psychiatric Care Technician F locked a patient in their room without following the established protocol to do so on 12/20/2020. The "self report" submitted to DQA documented "LAW ENFORCEMENT INVOLVEMENT: Was law enforcement contacted or involved? NO."

An interview was conducted with Quality Management Nursing Supervisor H on 4/27/20210 at 9:50 AM who, when asked, if police were contacted in regards to investigation of Psychiatric Care Technician F stated "No we did not."

Examples of no "Return to Duty" Plan:

Psychiatric Care Technician F was put on administrative leave on 12/21/2020 and returned to work on 2/23/2021. Psychiatric Care Technician F was scheduled to return to work on 2/24/2021 but resigned prior to shift. There was no documented counseling/teaching by the facility to Pasychiatric Care Technician F prior to returning to work duties.

An interview was conducted with Quality Management Nursing Supervisor H on 4/26/2021 at 11:45 AM who, when asked if Psychiatric Care Technician F received retraining on the facility seclusion policy prior to returning to work stated "No. We did not do that with him. I am not sure why we didn't we usually do."