Patients in Peril
The Journal Sentinel spent six months investigating problems at the Milwaukee County Mental Health Complex. The newspaper found a cascade of problems, including a case where a patient with a history of violence was allowed to roam free, doctors orders were not followed and nurses falsified documents to cover their mistakes.
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A patient who died Oct. 6 at the Milwaukee County Mental Health Complex told staff there repeatedly over three days that he had become paralyzed from a fall, begging to be taken to another hospital.
But even though the patient, 25-year-old Brandon Johnson, remained lying on a mattress on the floor or propped up in a "geriatric chair," staff at the county complex doubted his story, according to a federal health inspection report obtained Friday by the Journal Sentinel. A geriatric chair is a special reclining chair commonly used in nursing homes.
"The lack of monitoring, assessing, evaluation and providing appropriate intervention led to the death of" Johnson, the report says.
The treatment Johnson got at the complex in Wauwatosa was found so deficient that the federal Centers for Medicare and Medicaid Services declared the county complex a risk to patients and in danger of losing its federal funding.
"We have determined the deficiencies are so serious that it constitutes an immediate jeopardy to patient health and safety," a letter from the federal agency said.
The county submitted a plan of correction to address problems raised by federal inspectors, including failing to give Johnson a full physical assessment when he was admitted and shortcomings in monitoring him.
The federal agency accepted the county's corrective action plan Friday, according to Paula Lucey, administrator of the county's Behavioral Health Division. A follow-up inspection is expected in the next week, and if remedial steps are verified, the threatened loss of federal aid would be lifted, according to a letter from the federal agency.
County Executive Chris Abele said extensive work was being done to review the Johnson case and find out what went wrong. He said he will hold staff accountable if they're found culpable. But he also is focused on reforming the county's mental health system, he said.
"We take it extremely seriously," Abele said. "This is clearly unacceptable."
Johnson's death and the death of another patient at the complex in July, Paul Haugan, should serve as a wake-up call that more needs to be done to improve mental health services, said Barbara Beckert, manager of the Milwaukee office of Disability Rights Wisconsin. The agency is investigating Johnson's death.
"When you look at the specifics of this, it's extremely troubling," Beckert said.
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She had not seen the federal inspectors' report, but said her agency had reviewed Johnson's medical records from his stay at the Mental Health Complex.
According to the inspectors' report:
Johnson was brought by Milwaukee police to the Mental Health Complex about 8 a.m. Oct. 3 after his family reported irrational behavior, such as standing outside in his sleepwear, "looking confused, drooling, unresponsive and crawling down the stairs on hands and knees." He was described as appearing physically healthy when he was admitted.
At 5:15 p.m., a nurse's aide heard a call for help and went to Johnson's room with a nurse. They found Johnson on the floor, complaining he couldn't move his legs. Johnson repeatedly asked for help.
A psychiatrist at the complex wrote in his patient notes that "it is highly unlikely (Johnson) had a traumatic fall or injury," noting there were no outward signs of injury and that he had a history of similar behavior at home where he would remain lying on the floor, according to the inspection report.described as a third-year resident.
Staff notes on Johnson during his three-day stay repeatedly suggest they thought he was faking the paralysis, stating that he continued to "claim he was paralyzed."
By his second day at the complex, the staff noted that Johnson had become incontinent and continued to complain of paralysis.
He was helped into a geriatric chair at 6 a.m. the day he died. He was found dead at 9:20 a.m.
Johnson died from complications of a broken neck - a pulmonary embolism, according to a news release by Sheriff David A. Clarke Jr. The medical examiner's report has not been publicly released.
A series of remedial steps were taken at the county complex after Johnson's death, including training on patient care, assessment techniques and training for patients considered at risk for falls. Staff members also have been encouraged to report concerns about patient care to hospital administrators.
More than 575 employees and medical staff members have been educated on more rigorous care policies, according to Lucey.
An order was issued Oct. 12 stating no medical concerns raised by patients should be attributed to a psychiatric disorder unless medical issues are ruled out..
Beckert, the patient advocate, said the Johnson and Haugan deaths were unfortunate reminders that despite a heavy focus on reforms at the complex during the past two years, more work needs to be done. A 2010 inspection report found patient sexual assaults and other care shortcomings.
A Journal Sentinel series, "Patients in Peril" found a patient at the complex who became pregnant, her apparent attacker a sexually aggressive male patient who was housed near vulnerable women.
Beckert said the latest cases raise questions about whether the county should remain in the business of providing direct patient care.
Jonathan Safran, an attorney representing Johnson's family, called details contained in the inspectors' report "devastating."
"It certainly exhibits an absolute disregard of the health care of someone who is obviously exhibiting medical distress," Safran said.
Hear, hear Crispin. 
Now that is funnier than anything I've ever posted 
