MADISON — Wisconsin health officials launched nearly 100 investigations at the state veterans home in King based on incident reports and complaints between 2012 and 2016, according to a report state auditors released Wednesday.
The Legislature Audit Bureau report reveals details not previously available about investigations that had been reported in a 2017 audit. King has been heavily criticized in recent years for failing to keep nursing positions filled, excessive overtime and a culture of retaliation.
The 2017 report found the state Department of Health Services issued 184 citations against the home. However, two years ago the bureau couldn't get information on 90 citations that resulted from state investigations into incident reports or complaints. The state health department said then that it couldn't supply that information because the department acts on behalf of the federal government.
Auditors subsequently filed a request for data on those 90 citations from the federal Centers for Medicare and Medicaid Services under the Freedom of Information Act. State Auditor Joe Chrisman wrote in a letter to lawmakers Wednesday that the centers provided partially redacted reports in February 2019, nearly two years later.
The data is limited to only incident reports and complaints the DHS investigated between 2012 and 2016.
According to the audit bureau's report, the department conducted 90 investigations during that span. Forty of them were substantiated, resulting in 22 citations, including eight for violating restraint use and abuse standards, seven for violating quality of care standards, three for violating standards for resident services, two for violating administrative standards and two for violating residents' rights.
None of the 22 citations were for violating safety or quality of life standards. Only one of the 22 citations was for substandard quality of care. That citation was issued because King workers didn't provide CPR or arrange for emergency transportation for a 94-year-old resident found not breathing without a pulse. That incident resulted in a $76,900 civil penalty against King in June 2016.
State Department of Veterans Affairs Secretary Mary Kolar, in a letter included in the report, downplayed the significance of the findings because the data is years old.
She said since Gov. Tony Evers appointed her in January the department has renewed its focus on operations at all its veterans homes. She added she filled an open veterans homes administrator position in April after it had been vacant for nearly two years. Kolar called the job a "crucial oversight and management position."
