Gov. Scott Walker ordered the review after a Cap Times investigation in August revealed concerns from employees and residents about conditions and quality of care at the state-run home in Waupaca County.

The medical errors are a part of 14 total federal citations issued to the home following a two-week inspection in September. The citations are issued by the Wisconsin Department of Health Services on behalf of the federal government. DHS contracts with the federal government to inspect and certify nursing homes statewide that receive Medicare and Medicaid funding.

The average number of federal citations, or deficiencies, for nursing homes nationwide was 5.7 in 2014, the most recent year data was available, according to a 2015 report from the Centers for Medicare & Medicaid Services. That average has been decreasing steadily since 2008, when the average was 7.1, according to CMS.

Inspectors issued four federal citations at King’s MacArthur Hall and 10 at Olson Hall, according to its report. Federal law requires the home respond to citations with a plan of correction or risk losing its federal funding. The home has submitted a correction plan, and said the problems have been fixed or are being monitored. The correction plan is the nursing home’s written response to the inspection report, but is not an admission that the citations are accurate or valid. 

Officials at the Wisconsin Department of Veterans Affairs, which operates the King veterans home, did not immediately respond to a request for comment, but they have maintained that concerns over the quality of care there are unsubstantiated.

Veterans agency Sec. John Scocos has disputed accounts by employees, former employees and residents, and has said the home is of the highest quality, citing its repeated four- and five-star ratings from the Centers for Medicare & Medicaid Services. A five-star rating is the highest rating a nursing home can receive in the CMS ranking system.

“These entities have said that our homes are among the best in the country … if issues arise during these inspections, corrective action plans are put into place urgently so that we may make the improvements,” Scocos told the Joint Legislative Audit Committee in September. “We are still the very best in the country.”

In the DHS report, the most serious citations include 38 instances of medical errors in MacArthur Hall, including residents being given the wrong medication, incorrect dosages or never receiving needed medicine. In some instances, prescriptions were transcribed incorrectly, but several mistakes were attributed to changes in the nursing home’s software for administering medicine, according to inspectors. There were also instances of incorrect medical record keeping.

One resident in MacArthur Hall who was supposed to receive 12 units of insulin was given 100 units, according to inspectors. The licensed practical nurse who made the error told an inspector that she erred because she did know how to use the nursing home’s new software. She was trained on the program a month before the incident, but then went on vacation. When she returned, she was told by a supervisor that she did not have to get additional training and could just “wing it,” according to the report. The nurse said that when she asked another supervisor questions about the program, the supervisor told her “I don’t know what to tell you.” The nurse said the resident did not experience a negative impact from the insulin error, according to the report.

Another MacArthur resident who was ordered by a doctor to be off of blood thinners and aspirin was given the medicine anyway.

In another case, a resident mistakenly received someone else’s medicine: 5 milligrams of Zolpidem, a sedative used to treat insomnia; 300 milligrams of Gabapentin, a nerve drug to treat epilepsy; and 5 milligrams of Atorvastatin, used to treat high cholesterol.

In its plan of correction, the home’s administrators said they would update its electronic charting system to document errors and follow up. A nursing supervisor in MacArthur Hall will also audit medication errors for three months and re-train nurses and aides on the software, according to the correction plan.

There were more than 70 instances of food safety violations in Olson Hall’s kitchen which had the potential to affect all of the residents there, according to the DHS report.

Inspectors also cited Olson Hall for failing to provide a fire alarm system in several rooms in violation of the Life Safety Code, a national standard for buildings from the National Fire Protection Association.

Otis Woods, who oversees nursing home inspections at DHS, said the agency is fair, thorough and independent in its review of the King veterans home despite being a state agency reviewing a nursing home run by another state agency.

DHS acts in dual capacities when regulating nursing homes in Wisconsin. Its inspectors review nursing homes in order to issue or renew a home’s state license, but DHS also inspects homes on a complaint-driven basis to determine whether it should receive federal Medicare and Medicaid dollars. Both kinds of on-site inspections typically take a week.

The agency must meet the terms of its contract with the federal government to ensure money is being spent appropriately, Woods said.

“Our responsibility is to protect and promote the safety and welfare of the citizens of Wisconsin,” he said. “Because we are a regulatory body, we are as independent as you can potentially get.”

DHS has teams of inspectors located at regional offices throughout the state who are dispatched to conduct investigations of nursing homes. Inspectors are extensively trained and examine records, interview staff and residents when reviewing a home, Woods said. When reviewing complaints, inspectors investigate how widespread the problem may be, how severe, if there is a pattern and how many people it could affect.

The agency delivers its inspection results to the federal government, which checks the information and ultimately determines the outcome of a citation.

State auditors have also begun reviewing complaints at the Wisconsin Veterans Home at King. The audit, approved by lawmakers from both parties last month, is expected to take at least six months.