Winnebago cited for 3 deaths, rape: Poor supervision, bad judgment put patients in jeopardy at state-run mental health institute.

Byline: Mary Zahn

Sep. 2--JOURNAL SENTINEL WATCHDOG REPORT

Three patients died and a fourth patient was raped, prompting citations for neglect and inattention at the state-run Winnebago Mental Health Institute near Oshkosh.

Nearly three dozen other acts of violence or sexual aggression have been reported at the 134-year-old psychiatric hospital, which houses some of the most acutely mentally ill patients in Wisconsin. All the incidents, including the three deaths, occurred over a two-year period.

Winnebago received widespread publicity this year after a man escaped from the facility and later killed himself. Inspectors found no violations in that incident. But in site visits last year, regulators found numerous problems.

Inspection reports obtained by the Journal Sentinel under the state's Open Records Law show how poor supervision, questionable medical care, inadequate staffing and bad judgment placed patients in jeopardy, sometimes costing them their lives.

Among the cases cited:

--A 15-year-old girl with swallowing problems was taken off her special diet of soft foods. She later choked to death on a sandwich.

--A 14-year-old-girl was sexually assaulted in a shower by a 13-year-old boy. Both patients were supposed to be under constant supervision.

--A 24-year-old woman complained of dizziness to nurses, but her complaints were disregarded. Less than two hours later, she was dead.

--A 40-year-old patient brought to Winnebago after attempting suicide was left unsupervised. She went into a bathroom and drowned in the bathtub.

--A 27-year-old male patient stabbed a 37-year-old female patient in the neck with sharp scissors while she was making Christmas decorations. The staff didn't call 911, according to police reports. She nearly died.

"It is scary here," one patient told a state surveyor in August 2006.

The psychiatric hospital has about 225 patients, about 20% of them juveniles. Most are sent there by a civil or criminal judge for treatment or evaluation, sometimes after being charged with a violent offense.

Last year Winnebago was cited …