The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MILWAUKEE COUNTY BEHAVIORAL HEALTH DIVISION 9455 W WATERTOWN PLANK RD MILWAUKEE, WI 53226 May 8, 2014
VIOLATION: FORMULARY SYSTEM Tag No: A0511
Based on staff interview, the hospital medical staff failed to establish a hospital formulary that listed medications kept on-site and medications readily available to medical and nursing staff before and after pharmacy hours. This occurred in 2 of 2 interviews with hospital staff (E and Q) and 1 of 2 interviews with contracted hospital staff (F).

Findings Include:

In interview with Contracted Pharmacy Director F on 4/23/14 at approximately 3:30 PM, F states "not to her knowledge" when asked if the hospital has a drug formulary.

In interview with Director of Quality Q on 4/24/14 at approximately 12:30 PM, Q states that the hospital does not have a drug formulary that lists drugs maintained or readily available used by the hospital.

In interview with Medical Director E on 4/24/14 at approximately 12:30 PM, E states that the hospital does not have a drug formulary that: 1) lists drugs used and prescribed by the hospital medical staff, and 2) is reviewed periodically by medical staff to ensure that the pharmacy is stocking drugs used and needed by medical staff.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review and staff interview, the hospital failed to ensure that 2 of 2 medication variance reports (2013 and 2014) documented goals set for improvement and documented improvement plans for achieving those goals.

Findings include:

The 4/24/14 review of the "2013 Medication Variance Report" for year quarters 1,2,3 and 4 was conducted on 4/24/14 at 4 PM. There was no documented evidence of goal setting for collected medication error data to ensure that reductions in medications errors were decreasing in the hospital/ or on hospital units. There was no documented evidence that a medication variance reduction plan was developed to reduce errors from analysis of error "explanations", error "comments" or errors "recommendations".

The 4/24/14 review of the "2014 Medication Variance Report" for year quarter 1 was conducted on 4/28/14 at 5:30 PM. There was no documented evidence of goal setting for collected medication error data to ensure that reductions in medications errors were decreasing in the hospital/ or on hospital units. There was no documented evidence that a medication variance reduction plan was developed to reduce errors from analysis of error "explanations", error "comments" or errors "recommendations".

In interview with Safety/Risk management Nurse R on 4/28/14 at 5: 30 PM, who collates and analyzes medication variance data, R states that no QI (quality improvement) plans with goals and interventions have been documented for the hospital.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record review and staff interview, the hospital failed to ensure that 3 of 8 patients (3, 4, 5) reviewed had drugs administered according to physician's orders. This occurred in a total sample of 8 patients, and this could affect the total population of 8 patients on the acute psychiatric children's unit.

Findings include:

Clinical record review were made on 4/28/14 at 1 PM through 5 PM, while accompanied by EMR (Electronic Medical Record) Specialist H and DON (Director of Nurses) G.

1) Review of Patient #3's Client Profile-Order Details" reflects that on 4/27/14 at 5:11 PM, Physician M ordered "Guanfacine (sedative) 2 mg. oral tablet at bedtime". Review of the eMAR (electronic medication administration record) produced by H documents that this medication was not administered by nursing staff on 4/27/14 at bedtime (scheduled at 9 PM on 4/27/14 by eMAR). There was no documented evidence in the electronic medication "notes" or the "nursing notes" that would explain why this mediation was not administered per medical order.

In review and interview of this Patient #3's eMAR with G on 4/28/14 at 2:55 PM, G stated that there was no documented evidence that this medication was given as medically ordered.

2) Review of Patient #4's Client Profile-Order Details" reflects that on 4/13/14 at 5:35 PM, the PCS (Psychiatric Crisis Services Unit) Physician N ordered "Seroquel XR (long- acting anti-psychotic) 300 mg. oral tablet extended release at bedtime". The medical order for this medication was transferred to the acute in-patient unit at 10:05 PM, when the patient was admitted and transferred. Review of the eMAR (electronic medication administration record) produced by H documents that this medication was not administered by nursing staff on 4/13/14 at bedtime (scheduled at 9 PM on 4/27/14 by eMAR). There was no documented evidence in the electronic medication "notes" or the "nursing notes" that would explain why this mediation was not administered per medical order.

Review of Patient #4's Client Profile-Order Details" reflects that on 4/16/14 at 9:22 AM, Physician O ordered "Olanzapine (anti-psychotic) 5 mg oral tablet, disintegrating three times a day". Review of the eMAR (electronic medication administration record) produced by H documents that the third dose of this medication was not administered by nursing staff on 4/21/14 (scheduled at 8 PM on 4/21/14 by eMAR). There was no documented evidence in the electronic medication "notes" or the "nursing notes" that would explain why this mediation was not administered per medical order.

In review and interview of this Patient #4's eMAR with G on 4/28/14 at 4:34 PM, G stated that there was no documented evidence that these medications were given as medically ordered.

3) Review of Patient #5's Client Profile-Order Details" reflects that on 4/26//14 at 12:09 PM, the PCS (Psychiatric Crisis Services Unit) Physician P ordered "Wellbutrin XL 150 mg. (antidepressant) oral tablet, extended release, 24 hours once daily-first dose on 4/26/14 upon admission to 53B". (*53B is children's acute psychiatric unit) The medical order for this medication was transferred to the acute in-patient unit at 3:20 PM, when Patient #5 was admitted and transferred to in-patient unit. Review of the eMAR (electronic medication administration record) produced by H documents that this medication was not administered by nursing staff on 53 B on 4/26/14. There was no documented evidence in the electronic medication "notes" or the "nursing notes" that would explain why this mediation was not administered per medical order.

In review and interview of this Patient #5's eMAR with G on 4/26/14 at 3:41 PM, G stated that there was no documented evidence that this medication was given as medically ordered.