Early one morning last summer, 79-year-old Korean War-era veteran William Senn left his nursing home building, walked toward a lake on the property, and apparently had a heart attack. He was found hours later, drowned in 12 inches of water.

Inspectors cited the state-run Veterans Home at King for failing to conduct a thorough search for Senn after workers noticed he was not in the dining hall for breakfast or in his room.

The citation was one of an increasing number of federal regulation violations the Wisconsin Department of Health Services has found at King.

The number of deficiencies increased to 31 last year from 19 in 2007.

Inspectors make surprise visits to nursing homes about once a year and evaluate the quality of care. They also respond to complaints and reports from home administrators.

Overall quality ratings were average or better for each of King’s four residence halls, but those marks were graded on a curve against other Wisconsin nursing homes. Experts say the whole industry is struggling and being above average may not mean a great deal.

Randy Nitschke, top administrator for King and two smaller state Department of Veterans Affairs homes, said the increase in citations occurred because federal officials periodically pressure state inspectors to find more shortcomings.

“It doesn’t surprise me,” Nitschke said. “It’s an industry that’s underfunded and overregulated.”

King’s 2013-15 budget request blames low staffing levels for 12 citations for failing to control infections since 2004 and says more workers are needed for a resident population with worsening health needs.

‘Immediate jeopardy’ citations

Last year’s increase in citations came as nurses and aides complained that their numbers had fallen far behind growing occupancy at the home, and as the state prepares for another push to fill more of King’s 721 beds.

Some of the most serious violations included indications that staff members weren’t spending enough one-on-one time with disabled residents, and that training was insufficient.

Only two of the deficiencies since 2007 posed “immediate jeopardy” — conditions likely to cause serious harm or death to residents. In both instances, one residence hall was designated as providing substandard quality of care until changes were made.

According to DHS inspection reports on the “immediate jeopardy” citations:

• At Stordock Hall in 2008, staff members weren’t giving enough one-on-one attention to disabled residents.

One with a history of falls was found hanging with his face bruised and his throat caught in his bed’s side rail. He was turning blue. Staff members then removed the rail and placed the bed 8 inches from a wall, creating a dangerous entrapment risk.

Another man fell multiple times, twice suffering facial injuries. Still, inspectors found him unattended on a high bed with his door closed, contrary to his safety plan.

The home also failed to provide the expected level of supervision for a resident who was unable to smoke safely. A burn hole was found in the man’s footwear.

• At MacArthur Hall in 2010, patients were found with worsening bed sores, and staff weren’t receiving training on how to prevent them.

Deficient training

Inspectors linked deficient staff training on safety policies to Senn’s death on Aug. 6. The inspection report includes statements from several Olson Hall workers who didn’t follow the “missing members” policy by alerting supervisors to Senn’s absence so that a wider search could be ordered.

Between 7 and 8 a.m., a nursing assistant was told that a routine check showed Senn was missing from the dining area. The assistant went to Senn’s second-floor room. He wasn’t there, but instead of notifying others so that a search could start, she became busy with other residents who needed help.

At least two other staff members in the breakfast area also became busy and forgot.

Waupaca County’s emergency dispatch center was called around 11:20 a.m. after someone spotted Senn’s body just off shore in Rainbow Lake, which forms the west boundary of the King grounds.

The inspection report said Senn had heavy blockage of his coronary arteries, and he may have suffered a heart attack before he fell into the lake and drowned.

Nitschke said Senn was very independent and that even if workers had found him outside near the lake, they simply would have reminded him to check out before leaving the building.

A state investigation indicated several staff members and supervisors misunderstood the policy, which called for security personnel and outside law enforcement to search the grounds if other staff can’t find a missing resident.

Home administrators said understaffing wasn’t a cause of the problems, but employees said they have been placed in untenable situations that put their nursing licenses at risk.

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