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Editor’s note: This is the second of a two-part series on Wheaton Franciscan Healthcare’s mental health unit.

Ascension’s mental health unit in Racine has had to address several operational issues with the state and the Center for Medicaid and Medicare Services.

Ascension signed a letter of intent in October with the Wheaton Franciscan Sisters to take over all of its operations and corporate services in Southeast Wisconsin; eight hospitals, 350 medical group physicians, outpatient centers, transitional and long-term care facilities, home health and hospice, and nearly 11,000 associates as well as its corporate services.

Staff from the Division of Quality Assurance who surveyed the unit found the facility on March 15 was out of compliance with its conditions of participation, nursing services, physical environment and patient rights laws, according to the Department of Health Services.

This resulted in the hospital being found out of compliance and it lost “deemed status and accreditation” until it corrected those deficiencies. On May 3, DQA staff determined that the hospital was able to meet those conditions of participation to meet the Medicare requirements based upon accreditation by The Joint Commission (on healthcare).”

Click here to read the March 15 survey and Plan of correction

State Identifies Patient Safety Issues

Staff failed to keep patient care plans updated when patients have a change of condition and implement and apply appropriate monitoring and interventions as identified in 2 of 10 medical records reviewed.

Surveyors noted evidence of missing documentation on the safety precautions record logs in two patients’ records. They discovered insufficient and inconsistent documentation of the level of precautions in both of these records. They also found no evidence of the treatment plans being updated to reflect changes in safety precautions levels for either of these two patients.

A woman tried to commit suicide in November, and she was hospitalized on the mental health unit at Wheaton Franciscan Hospital. Her doctor ordered staff to check on her every 15 minutes and that “certain objects may be removed from the patient’s room to provide safety of the patient and others.” But checks were not always done every 15 minutes and an employee found the woman blue in the face and “sitting in a shower, not responding to (the staff member).”

There was a piece of cloth wrapped around the woman’s neck, and the same thing happened again a week later, according to the state survey. Even after the first suicide attempt, the woman had unsupervised access to towels despite how she was found with cloth around her neck. Records showed “no evidence of staff reviewing and updating plan of care goals and documenting individualized interventions” following the two in-hospital suicide attempts.

The plan of correction required that the unit do compliance monitoring through July 29.

Ascension Resets Mental Health Unit

This isn’t the first time the mental health unit has had staffing and safety violations.

Acting on several complaints, surveyors from the State Division of Quality Assurance (DQA), and the Center for Medicare and Medicaid Services (CMMS) conducted an unannounced visit in May 2015 to the children and adolescent unit, and adult inpatient mental health units at 1320 Wisconsin Avenue.

The mental health unit had a new staffing model, which included working with Medicus Firm, a company that provides temporary psychiatrists to staff the unit until the hospital was able to recruit full-time psychiatrists. Because of a national shortage of psychiatrists, the hospital expected the transition to take up to nine to 12 months, said Chief Operating Officer Paul Mason last year.

Karen Molnar-Smith, administrative director of the unit, wrote a memo to staff in June about Ascension Wisconsin’s restructuring plan. In that memo, she mentioned that the adult unit had to run for nine months using the temporary psychiatrists “just to be able to keep the unit open.” As a result, Ascension reduced the annual average daily census for the adult inpatient unit from 27 to 16 beds because the unit “lost significant inpatient volume due to internal challenges, as well (as) some external factors.”

Sources tell the Racine County Eye that those temporary psychiatrists are gone and at least a dozen people in the mental health unit were laid off in June and July along with some staff being offered jobs with reduced hours.

Ballantine, who was also affected by the restructuring, issued the following statement prior to her leaving the company in July:

“Based on operational and programmatic changes, a limited number of associates will be leaving or taking new roles in our organization. While challenging, these decisions are made in the context of our goal to provide high-quality and compassionate healthcare as efficiently and effectively as possible.  We will do everything we can to ensure a smooth transition for those affected,” she said.

Click here to read the first story.


Denise Lockwood has an extensive background in traditional and non-traditional media. She has written for, the Milwaukee Business Journal, Milwaukee Magazine and the Kenosha News.

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