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Whistleblower complaint about liquid oxygen hazard at King veterans home validated

Wisconsin State Journal - 12/30/2016

Dec. 30--A whistleblower complaint regarding a hazardous liquid oxygen spill at the state-run nursing home for veterans in King has been substantiated, according to a federal agency.

The complaint alleges security personnel at the facility were alerted to the hazard earlier this year, but were instructed not to file an incident report. They ultimately filed a one-paragraph report after a maintenance staff member insisted they do so.

The state Department of Health Services investigated the allegation twice before substantiating it, according to Jan Suzuki, a regional manager for the Centers for Medicare & Medicaid Services, which contracts inspections of state-run veterans homes to state health agencies. The state Department of Veterans Affairs runs the facilities.

No citation was issued for the incident because the situation had been remedied, but seven citations were issued for other unrelated issues as part of the December inspection, Suzuki said.

Sen. Luther Olsen, R-Ripon, whose district includes King, said he was particularly concerned about the allegation that security personnel were instructed not to file a report.

"The issue is this was reported to the leadership at King and they kept it quiet," Olsen said. "From what I understand, when something like this is reported, you're supposed to report this to the feds, and maybe the state, and they didn't do it, and that's what concerns me."

"If this is the M.O. that we're turning a blind eye to this stuff ... that was serious," Olsen added. "That place could have blown up."

The incident is the latest in a series of problems at the veterans home that have resulted in its residential care units having their health-care ratings downgraded in recent months.

As recently as October, Gov. Scott Walker and DVA Secretary John Scocos countered claims of poor living conditions and management problems at King by touting its four facilities receiving five-star ratings.

Since then the ratings have been downgraded at two of the facilities, Olson and MacArthur halls, due to poor care connected to a 94-year-old resident's death and seven citations identified during a September inspection.

Walker has announced Scocos plans to resign Jan. 7. Walker spokesman Tom Evenson said Thursday the office is going through the appointment process and referred questions about the incident to DVA and DHS.

Spokeswomen for the agencies did not respond to requests for comment late Thursday.

The liquid oxygen incident took place in an underground tunnel connecting Olson and MacArthur halls, according to the complaint. A maintenance worker saw white fog coming from a room where oxygen tanks are refilled and called security.

Upon inspection they saw that an opened valve was allowing liquid oxygen to leak into the ventilation system.

"By the grace of God, there were not any active heating elements, sparks or open flames that could have easily ignited an explosion that would have potentially destroyed King facilities causing a mass casualty incident," the whistleblower wrote.

The complaint says a staff member at the facility, an Air Force veteran with experience handling highly flammable liquid oxygen, had been trying to get management "all the way up to Madison" to address concerns about the handling of the hazardous material for 2 1/2 years.

When the staff member discussed the incident with the security chief, the chief told him "he had been directed not to detail security incident reports any longer due to open records exposures."

The whistleblower, who also works for Veterans Affairs, provided the complaint to Columbia County Veterans Services Officer Richard Hasse, who said he forwarded it to several state lawmakers. Sen. Jon Erpenbach, D-Middleton, forwarded it to CMS on Sept. 30.

On Wednesday, Suzuki informed Erpenbach that DHS had investigated the incident on Oct. 10, but found no evidence of non-compliance. The state agency conducted a more thorough review as part of a recertification inspection in early December and found "the allegations were valid."

"The surveyor substantiated the complaint allegation, but as the facility had completely identified and corrected the violation, no citation was issued," Suzuki wrote. "This is consistent with CMS's policy regarding citations of past non-compliance."

Both Olsen and Erpenbach said they hope to see issues at King addressed by the new Veterans Affairs secretary.

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(c)2016 The Wisconsin State Journal (Madison, Wis.)

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