MILWAUKEE (AP) - Three patients died and another was raped among nearly three dozens acts of violence or sexual aggression at the state-run Winnebago Mental Health Institute near Oshkosh over a two-year period.
Regulators have found numerous problems that have led to citations for neglect and inattention at the 134-year-old psychiatric hospital that houses some of the most severe mentally ill patients in the state.
Inspection reports obtained by the Journal Sentinel using the state's Open Records Law show poor supervision, questionable medical care and inadequate staffing put patients in jeopardy.
But this year, state authorities say there have been no deaths and nine physical assaults.
The three deaths were Myriah Peronto, 15, who choked on a sandwich after being taken off her special diet of soft food; Sarah Duffin, 40, who drowned in a bathroom after being brought to the hospital following a suicide attempt and Destiny Mallon, 24, who complained of dizziness to nurses, but never received help and died two hours later.
A 14-year-old girl also was sexually assaulted in a shower by a 13-year-old boy. Both patients were supposed to be under constant supervision.
"It is scary here," one patient told a state surveyor in August 2006.
The psychiatric hospital has about 225 patients. About 20 percent of them are juveniles and most are sent there by a civil or criminal judge for treatment or evaluation.
Last year Winnebago, which opened in 1873, was cited by state inspectors with 24 federal rule violations involving at least two dozen patients.
The hospital was ordered to fix its problems by 2008 or lose its federal Medicaid and Medicare funding.
Winnebago director Robert Kneepkens said last week all the violations have been corrected except that the hospital needs to fix or eliminate items that could be used in a suicide attempt. That includes securing exposed pipes that patients could access above the ceiling.
"Patient and public safety is always paramount here," Kneepkens said.
In 2005, the hospital was inspected by the Joint Commission, a national group that evaluates and accredits hospitals nationwide, and met the standards of accreditation.
But inspectors have visited the psychiatric hospital 15 times since 2001, all on specific complaints, records show.
"The point of a state hospital is to give people who meet the standard of being a danger to themselves or others time to decompress and get their act together and get some treatment," said Kristin Kerschensteiner, managing attorney for Disability Rights Wisconsin, a statewide, federally funded advocacy group. "What they are getting is fear and concern for their safety. It is very serious."
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Peronto's mother, Shannon Peronto, said she wanted her daughter, who suffered from seizures and related behavioral problems before she died Jan. 11, 2006, to get good care.
"I was told this was the best place in the area, period," Peronto said. "Knowing what I know now, I would not put her in that hospital."
Other problems came about because of poor supervision.
In the rape on May 19, 2005, both the girl and boy were bipolar, mildly mentally retarded and under orders to be accompanied by staff when they were out of their rooms.
However, staff members weren't with either patient when the boy pushed the girl into the girl's shower and raped her as she screamed, according to inspection and police reports.
By the time staff arrived, they found her lying in a fetal position, bleeding. The boy was arrested, but the hospital failed to report the caregivers to the state for possible discipline, state records show.
Duffin was admitted after a drug overdose, and staff placed her bed in the hallway next to the nurses' station to allow for constant supervision and to check on her every 15 minutes.
But two days after she was admitted, the staff lost track of her, and she was found dead in the male shower room, face down in a bathtub on Sept. 12, 2005.
Medical staff also failed to assess the seriousness of Mallon's condition when she complained she was dizzy and weak on April 15, 2006.
A nurse gave the patient cough medicine, but she collapsed a short time later and was pronounced dead. The hospital was cited for failing to assess the woman when she complained of feeling ill and for not reporting a change in her condition to the doctor.
The Winnebago County coroner's report states Mallon died from a blood clot in her lungs.
Staff members also told inspectors in August 2006 they frequently worked exhausting hours and that the basic needs of patients were not being met because of a lack of staff.
Kneepkens said about 50 more employees who work directly with patients have been hired since those surveys and systemic changes have been made to address the inspection reports.
Information from: Milwaukee Journal Sentinel, http://www.jsonline.com