Granite Hills Hospital, located in West Allis, Wisconsin, opened in January 2022 and is a central part of Milwaukee County’s mental health system redesign. The Wisconsin Department of Health Services substantiated a woman’s complaint about the treatment of her relative and flagged a range of violations. (Devin Blake / Milwaukee Neighborhood News Service)
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Family members and mental health advocates have expressed concern about the safety of patients at Granite Hills Hospital, the psychiatric hospital contracted to serve Milwaukee County residents. 

Among those lodging complaints is Cynthia Berry-Roberson. For decades, she has helped manage the care of a relative with a severe mental illness. Milwaukee Neighborhood News Service is not naming the patient because of privacy concerns voiced by Berry-Roberson.

This relative was hospitalized at Granite Hills twice in 2022, totaling several months as a patient there.

“At first,” Berry-Roberson said, “Granite Hills seemed like such a really nice place, because it’s really new and modern and all that.”  

This sense of optimism was shared by many when Granite Hills opened in January 2022.

The hospital is a central part of the much-touted redesign of the county’s mental health system, a process intended to better serve those in need.

“The redesign focused on improving access to behavioral health services and quality care in our most underserved and vulnerable communities,” Milwaukee County Executive David Crowley said in a news release announcing changes involved in the mental health redesign.

Private hospital systems in the county, such as Advocate Aurora Health and Froedtert and the Medical College of Wisconsin also admit psychiatric patients, but these are usually people with private insurance.

Although Granite Hills is a private hospital, Milwaukee County contracts it to be its primary psychiatric hospital for “those who are indigent,” said Michael Lappen, administrator of the county’s Behavioral Health Division.  

Berry-Roberson’s relative lacks private insurance and was admitted to Granite Hills. The sense of optimism Berry-Roberson said she had about the prospects for treatment there quickly faded.

During one of the two hospitalizations, her relative, who is diabetic, was not being monitored according to protocol, Berry-Roberson said.

“They let her pile a mattress on top of another mattress … and she fell off it when she was asleep, and she hurt her arm,” she said.

Staff did not attend to the injury for three days, and it eventually developed into a Staphylococcus infection, Berry-Roberson said.

“If they had been checking on her — they should have never let her be on two mattresses. And the second thing is — they wouldn’t listen to her, to get medical help right away. Because she asked for it. I know she did because she called and told me,” Berry-Roberson said.

The relative’s arm was operated on, but Berry-Roberson said it will be an injury the relative must deal with “for the rest of her life.” 

Eventually, Berry-Roberson filed a complaint with the state’s Division of Quality Assurance, or DQA, a division within the Wisconsin Department of Health Services that helps monitor various medical facilities. 

The complaint pointed to the lack of adequate monitoring of the relative by Granite Hills staff and the failure to report the injury to her arm.

The DQA conducted an unannounced on-site inspection of Granite Hills in December 2022.

After the inspection, the DQA informed Berry-Roberson that her complaint was substantiated, stating in a letter, “The investigation found that there was sufficient evidence to confirm a violation(s) of state and/or federal requirements related to your concerns.”

The DQA inspection found several other violations: failure to properly restrain or seclude patients; failure to secure medication; failure to secure equipment; failure to administer medication in accordance with the orders of a physician; failure to provide food in accordance with those who require a diabetic diet; failure to follow building safety protocol; and failure to properly monitor those who are at risk for suicide.

While the inspection was conducted at the end of 2022, records requested from the West Allis Police Department reveal other safety-related concerns that took place throughout the year.

From January 2022 to January 2023, there were roughly 20 calls to the West Allis Police Department about battery or assault against patients by other patients. Several of these included sexual assault.

In that same period, there also were roughly 25 calls to the West Allis Police Department concerning battery or assault against staff by patients.

Staffing crisis vs. safety

Benjamin Peerbolt, the director of clinical services at Granite Hills, said in an email, “All issues and complaints are thoroughly investigated and reviewed. Our team strives for excellence each and every day, and we continually look for opportunities to improve our quality of service.” 

Lappen of the county’s Behavioral Health Division attributes the conditions at Granite Hills to several factors, including “failures around policy, procedure and the physical environment” but attributes much of it to the nationwide staffing crisis in health care.

“My sense is that turnover and staffing challenges are the root cause of many of the issues,” he said.

In an email, Robin Weagley, the then-interim chief executive officer also acknowledged the staffing crisis: “Like the entire health care industry, we are facing staffing challenges.”

Brenda Wesley, who just finished a term as the chairperson of Milwaukee County Mental Health Board Community Stakeholder Advisory Council, is more skeptical. 

“Even without a work shortage, the system wasn’t working,” she said.

‘We need to go back to the table’

Despite all the efforts that went into the redesign, many of the goals that were hoped for have not yet been achieved, she added. “We need to go back to the table.” 

The advisory council serves as a liaison and advocates on behalf of those who use the county’s mental health system.

Regardless of all the contributing factors, Lappen said the county and the facilities it works with have an obligation to keep patients safe and provide them with adequate care. 

“I absolutely think there’s work to be done,” he said.  

A more experienced staff would be better able to accomplish these goals, he said. 

Lappen said he worries, though, that reports about conditions at Granite Hills create a sort of self-fulfilling prophecy “because there are these horror stories about how they’re (Granite Hills)) not doing a great job and then it keeps people out of the door.” 

“But,” he added, “they have to figure that out.”

Weagley said Granite Hills has developed strategies “to continue to retain and to attract people to join the health care field doing fulfilling work.”

These strategies include sign-on and retention bonuses, tuition reimbursement, loan forgiveness programs, among others.  This story was originally published by Milwaukee Neighborhood News Service, a nonprofit news organization that covers Milwaukee’s diverse neighborhoods.

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Devin Blake started as a journalist at Patch, writing about the Southern California neighborhoods he grew up in. He focused on local business communities throughout the area and was drawn to stories about unemployment, worker resources, and businesses that were filling unmet needs in their communities.

Watching the homelessness crisis continue to deepen over those years, he began working as a resource and information coordinator for community groups and nonprofits so they could better serve populations without stable housing—populations that included the elderly, developmentally delayed and those with HIV/AIDs, among others.

Blake has contributed to a number of publications, including New York magazine, The Onion, and McSweeney’s. He loves spending time with his wife and negotiating with his 2-year-old son.