Greenfield - For more than 10 hours late one night and into the next morning, staff at the state's largest nursing home recorded on charts that a 41-year-old brain-damaged resident was in his room.
In fact, a state regulator's report shows, the man had fled Mount Carmel Health and Rehabilitation Center and was arrested for prowling more than four miles away.
When staff wrote that he was in bed watching TV, he was actually in the Milwaukee County Jail.
A citation for the staff's mishandling of the case is one of 35 health violations cited by state and federal investigators this year at Mount Carmel, which was nearly shut down by the state 12 years ago for repeated violations.
In response, Mount Carmel said in a statement that it is correcting the situation that allowed the resident to leave. And it says that, according to the Wisconsin Health Care Association, Mount Carmel "has had 37% fewer annual citations per bed as compared to the average number of citations per bed in southeast Wisconsin."
Records also show, however, that the 35 citations issued so far this year to Mount Carmel are close to the 40 citations issued in all of 2009 and more than the 25 issued in 2008, according to the state Department of Health Services.
The latest state report notes that the man who left the facility, 5700 W. Layton Ave., would have had to walk across streets, at night, that average 15,000 vehicles per day.
West Allis police arrested the man and issued him a citation for peeking into the windows of a home at about 8:30 p.m. May 16, according to a police report.
Police thought he was homeless and, because he had outstanding warrants in other cases, took him to the Milwaukee County Jail, the report says.
The man, a former Milwaukee and West Bend resident, spent five days in custody, according to the jail.
Mount Carmel staff members - who were to check on the man every 15 minutes because he had a history of trying to leave the facility - had continued to mark on charts that he was at the facility through the night and into the morning of May 17, the state inspection report says.
The other violations cited this year include failing to communicate with a recent amputee who speaks little English and failing to provide for five residents at risk of falling, including one who was hospitalized for a broken jaw after falling out of his wheelchair.
Paul Peshek, director of the state Bureau of Nursing Home Resident Care, said the state does not rank nursing homes but expects nursing homes to keep residents safe.
Licensed for 473 beds, Mount Carmel is the largest of the 397 nursing homes in Wisconsin, according to the Department of Health Services.
In 1998, the state revoked the license of Vencor Inc., Mount Carmel's owner at the time, after discovering serious and widespread health violations, nearly shutting down the facility. Benedictine Health System of Minnesota took over management and was credited with correcting most of the care problems within months.
In January 2009, Kindred Health Care, a Louisville, Ky., for-profit company that is a successor of Vencor, resumed operation of Mount Carmel. After operating with a probationary license for one year, Kindred was given a full license in January of this year.
The citations issued this year include two identifying "actual harm" to residents and five for violations that constitute a "direct threat to health, safety and welfare," state records show.
Among other things, Mount Carmel was accused of:
• Failing to provide appropriate supervision and assistive devices to five out of 10 residents identified by Mount Carmel as being at risk for falls.
Three of the five had fallen since last December, including one who suffered a broken jaw and an eye socket "blowout." A hospital that treated the woman reported the incident to the state but Mount Carmel, which was required to report the incident, did not.
• Failing to assess and treat pain, depression and other problems experienced by a 51-year-old woman who speaks Spanish and who had part of her right leg amputated last December.
Staff had access to a telephone interpreter service but told an investigator they relied on records, the woman's facial expressions and her limited English to communicate with her.
• Sixteen of 32 residents reviewed were not treated "in a manner that maintained their dignity."
Two were kept in a small alcove near an exit; at least six were kept in an old nursing station or in a hallway for extended periods; and an incontinent resident said staff turned off his call light four times after he sounded it and had a bowel movement before any staff took him to the toilet.
During another inspection last September, regulators found Mount Carmel "not in substantial compliance" with fire safety regulations. Among other things, an investigator found that the automatic sprinkler system was not properly maintained and that one of the nursing home's 16 exit areas was blocked by a temporary partition and that the doors in that exit area were locked.
The September inspection also found that after a resident complained of hip pain, Mount Carmel did not notify a physician for two hours and 15 minutes. The doctor ordered an X-ray, but the order was not relayed by a nurse for 2 1/2 hours. The X-ray revealed a broken hip.
The resident's legal representative had been notified earlier about the resident's pain, but was not notified about the broken hip until three hours after the X-ray results were known.
On the Web
To search for Wisconsin nursing homes that have been issued citations from April 2009 through March 2010, go to www.dhs.wisconsin.gov/bqaconsumer and click on Nursing home citations.
To file a complaint against a nursing home or other care facility, see File A Complaint at dhs.wisconsin.gov.
Summary of violations
Mount Carmel Health and Rehabilitation Center in Greenfield was cited for 35 state and federal violations so far this year. Among them:
March 2010: A 51-year-old resident who had her right leg amputated below the knee in December 2009 did not have staples removed as of March and no adequate assessment or treatment of the resident's "phantom pain" in the leg had been done.
Mount Carmel also was cited for failing to communicate with the resident, who did not speak English, in Spanish. Among other things, staff was not aware that the resident experienced phantom pain and that she had been dropped by staff. A registered nurse told an investigator she didn't need a Spanish interpreter because relied on documents and the resident's gestures and facial expressions.
Also in March, an investigator found that 16 of 32 residents reviewed were not treated "in a manner that maintained their dignity." Two had been transported in shower chairs with bare legs or buttocks exposed; two were kept in a small alcove near an exit; at least six were kept in an old nursing station or in a hallway for extended periods; an incontinent resident said staff turned off his call light four times after he sounded it and had a bowel movement before any staff took him to the toilet.
January 2010: A federal investigator finds that, going back to December, five out of 10 residents identified by Mount Carmel as being at risk for falls did not receive appropriate supervision and assistive devices, and that three of them fell. A 92-year-old resident who needed supervision was dropped off at a medical appointment by herself. .
Dec. 3, 2009: A resident who lacks the ability to move in bed, is found on the floor next to her bed. She suffers a broken jaw and an eye socket "blowout," according to a federal investigator. The hospital reported the injuries to the state Office of Caregiver Quality, but Mount Carmel, which is required to make a report, did not. When the investigator asked a Mount Carmel administrator on Jan. 11, five weeks after the incident, whether Mount Carmel had reported the incident to the state, the administrator said no report had been made because Mount Carmel "felt they knew how the incident occurred."
Nov. 5, 2009: Resident suffers laceration to left palm requiring sutures in a hospital emergency room. Hospital reports the injury to the state, but Mount Carmel did not. Mount Carmel could not determine how the incident occurred.