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DRW Investigation of Milwaukee County Behavioral Health Division and Recommendations

Disability Rights Wisconsin has monitored and reported on the conditions and treatment of individuals at the Milwaukee Mental Health Complex and Milwaukee County’s Behavioral Health Division for many years. This week the Milwaukee Journal Sentinel highlighted the work of DRW including an expert report and recommendations made earlier in the year. “Poor Care Called Factor in Four Deaths at Mental Health Complex”.

In 2013, DRW conducted a new investigation after the death of six patients at the Complex. The seriousness of the results of the investigation prompted DRW to hire  an independent board-certified psychiatrist to review the records of these patients. Dr. William Knoedler concluded that the Complex “is not a safe place for medically ill patients to be hospitalized.” As a result of this investigation, DRW issued a series of recommendations, along with Dr. Knoedler’s report and his own recommendations, on June 17, 2013 to the Milwaukee County Executive, the Wisconsin Secretary of the Department of Health Services, the Administrator of the Wisconsin Division of Quality Assurance in charge of licensing and citing such facilities, the Director of Milwaukee County Health and Human Services, and the acting Administrator of the Milwaukee County Behavioral Health Division. The report was also released to the federal Center for Medicaid and Medicare Services, which has regulatory authority for the complex. Because of the concerns raised regarding safety and quality of care, the report reinforced the urgency of closing Rehab Central, the nursing home, and Hilltop, a long term care facility for persons with developmental disabilities, and made the case for expansion of community based supports. DRW continues to advocate for patients at the complex with both county and State officials, including as a member of the closing team for these two components of the Mental Health complex.

DRW recommended “the immediate deployment of an independent interdisciplinary team of clinicians (at minimum, a psychiatrist, psychiatric nurse, systems/policy expert and someone familiar with administration and personnel issues for this type of facility) to review inpatient medical care, psychiatric treatment and patient safety at the Complex, with the goal of providing specific concrete and immediately implementable steps to sufficiently ameliorate the current situation. This plan would need to be quickly adopted and actively promoted with the medical and professional staff at the Complex, and implementation would need to be monitored by the interdisciplinary team for a period of months to ensure quality improvement and patient safety.”

DRW also recommended an immediate “voluntary hold on the admission of individuals who are being transferred directly from the acute units at the Complex, until there is a complete and comprehensive assessment of the long term nursing needs of that individual. Additionally, all current residents of these units should also undergo a thorough assessment to determine if they are actually appropriately placed at Rehabilitation Central.” To date, none of these recommendations have been adopted by the County.