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.

WILLOW CREEK BEHAVIORAL HEALTH 1351 ONTARIO RD GREEN BAY, WI 54311 Feb. 10, 2020
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on interview, the facility failed to inform patients of their rights by failing to disclose to their patients that there is not a medical doctor (MD) or doctor of osteopathic medicine (DO) present in the hospital at all times.

Findings include:

On 2/08/2020 at 4:17 PM during interview with Director of Quality Director H, Quality Director H stated the physicians work clinic hours and there was not a physician at this facility 24 hours a day, 7 days a week. Quality Director H confirmed patients did not get written notice that the hospital did not have a physician at this facility at all times.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review and interview, the facility failed to ensure an ongoing program that shows measurable improvement to identify and reduce medication errors in one of one Quality Performance Plans.

Findings include:

Review of "Medication Discrepancies and Medication Errors" policy #1700.30 reviewed date 1/2020, #4 revealed "Medication Variance (Incident) reports shall be reviewed ... and acted upon as appropriate."

Review of record titled "List of Performance Indicators & Scope of Services" for 2020 did not list the Pharmacy Department or medication variances.

Review of "QUALITY/PERFORMANCE IMPROVEMENT REPORT" dated December 19, revealed indicators collected for the Pharmacy Department included "Medication Error Rate%(calculated based on total doses dispensed) between 0.013 and 0.057, Adverse drug reaction rate (calculated based on total doses dispensed) between 0 and 0.0532 and "Medication error rate attributed to pharmacy error" 0.006 and 0, all were below their standard of "5" and threshold of "6" requiring continued follow-up.

On 2/06/2020 at 3:07 PM during interview with Quality Director H, Quality Director H stated that the standards and thresholds for the pharmacy indicators are "corporate decisions". Director H stated that when there was nothing that was above the standard or threshold, no further performance improvement with these indicators was done "at this time."

On 2/06/2020 at 3:13 PM during interview with Pharmacy Director J, Pharmacist J stated variance numbers are collected and given to Quality Director H . Pharmacist J confirmed his follow-up of the medication incident reports was complete once these monthly variance numbers were reported to H.