Report Summary

Title: Healthcare Inspection - Management of Mental Health Care Concerns, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin
Report Number: 16-00748-319 Download
Issue Date: 7/27/2017
City/State: Milwaukee, WI
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection Report
Release Type: Unrestricted

OIG conducted a healthcare inspection to assess allegations from Senators Tammy Baldwin and Ron Johnson in December 2015 and June 2016 concerning program policies and procedures, staffing, and quality of care in the Mental Health Residential Rehabilitation Treatment Program (MH RRTP) and Acute Mental Health Inpatient Unit (AMHIU) at the Clement J. Zablocki VA Medical Center (facility) Milwaukee, WI. We substantiated staff did not consistently follow MH RRTP patient safety policies. Staff did not consistently conduct or document rounds, maintain physical presence and engagement on the units, or conduct contraband checks. We substantiated MH RRTP staffing was inadequate and facility leaders had not assigned a dedicated MH RRTP psychiatrist.

We did not substantiate that a patient was given a higher than indicated buprenorphine/naloxone dose. The patient’s provider prescribed a dosage of buprenorphine/naloxone that was within suggested ranges for the patient’s phase of treatment. We focused our review of AMHIU safety and security on visitation procedures. We substantiated that in spring 2016, the unit did not have a visitation policy and staff did not consistently check visitors for contraband. We could not determine a failure to conduct contraband checks led to an attempted suicide or a patient having a syringe in his room. We substantiated an Administrative Investigation Board was conducted and 16 recommendations were issued. One recommendation addressed enhancing MH RRTP safety and security. We found increased police presence and measures to limit access to the MH RRTP during a second site visit in August 2016. We did not substantiate a patient was denied admission to an MH RRTP program. The patient was discharged due to his failure to comply with policies. We found that a Mental Health Treatment Coordinator (MHTC) was not identified in this patient’s electronic health record. We were unable to identify assigned MHTCs for six of seven other patients we reviewed. We determined facility aftercare programs were available during day, evening, and weekend hours. Six of the reviewed patients who required post discharge follow-up care appointments received appointments; however, not all attended the appointments. We recommended that the Facility Director ensure MH RRTP local policies are consistent with VHA’s MH RRTP Handbook, MH RRTP leaders and staff adhere to the policies, managers monitor compliance, the MH RRTP has adequate resources, the AMHIU visitation policy is fully implemented, MHTCs are assigned to mental health patients and communication and coordination is enhanced across mental health clinical areas.