Minnesota psych hospital fined as more cases of abuse uncovered

September 5, 2013

Investigators have documented two new cases of patient maltreatment and a number of serious record-keeping violations at the Minnesota Security Hospital in St. Peter, prompting authorities to fine the facility $2,000 and place it under an extended period of scrutiny by state licensing officials.

Human Services Commissioner Lucinda Jesson said in an interview Wednesday that she was “seriously concerned” about the two maltreatment incidents, which occurred in August 2012 and January of this year.

Jesson added, however, that she was heartened to see significant improvements at the hospital since December 2011, when she gave it two years to reduce unnecessary use of patient restraints and seclusion or face the revocation of its license.

The St. Peter hospital, Minnesota’s largest psychiatric facility and home to nearly 400 of the state’s most dangerous patients, has been plagued by a series of management breakdowns and cases of patient maltreatment.

In the latest incidents, state reports show that hospital staff members failed to intervene in August 2012 as a 59-year-old patient with a history of epilepsy and dementia repeatedly banged his head against a concrete wall for more than three hours.

Then in January, two members of the medical staff failed to obtain timely treatment for a patient who exhibited unusual symptoms after an apparent seizure. The hospital’s line staff tried to get the patient medical attention, but health care workers at the hospital were unable to get doctors to respond, records show. The patient waited more than four hours to receive advanced medical care and was found to have suffered a stroke.

Officials said the patient is in a nursing home and has made a nearly complete recovery.

Jesson said two health care workers were found responsible for the failure because they didn’t communicate their concerns clearly to physicians.

An investigative report released Wednesday by the Department of Human Services notes that the hospital has been working to correct its problems under the supervision of the agency’s licensing division. But it also cites the facility for a number of repeat record-keeping violations related to use of patient restraints and seclusion.

Jesson said the record-keeping violations alone would not have prompted her to extend the “conditional” status of the hospital’s license. She said some of those problems stemmed from rule changes governing the use of restraints and seclusion, which prompted changes in documentation requirements as well. Those changes take time to implement, she said.

“I think the thing that stood out to me the most was the incident where … we had a patient that continued to hit his head against a concrete wall and staff did not intervene,” Jesson said. She speculated that the staff was reticent after she put the hospital on a conditional license just eight months earlier, citing excessive use of restraints. Continued operations was conditioned on the reforms Jesson ordered.

She said Wednesday that an additional year of oversight is needed to ensure that the staff finds what she called the “right balance” in using restrictive methods to protect the patients. “We want to make sure that the pendulum doesn’t swing too far to the other side, where restraints aren’t being used when they’re appropriate to a patient’s safety,” she said.

That said, Jesson expressed confidence in the hospital’s new administrator, Carol Olson, and its new medical director, Dr. Steven Pratt, both of whom began working there this year. They could not be reached for comment.

Source: Dan Browning, "2 new cases of patient neglect found at St. Peter mental hospital," Star Tribune, August 28, 2013.