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Continued: Minnesota Security Hospital: Staff in crisis spreads turmoil

  • Article by: PAUL MCENROE , Star Tribune
  • Last update: January 1, 2014 - 8:54 AM

In an interview, Kerber acknowledged Christensen’s remark “was certainly a very blunt message’’ and said he has ordered the case referred to the state Board of Medical Practice.

Paperwork lapses

In addition, internal records show that performing the most basic patient-care tasks has often been difficult.

In the past four months, the hospital discharged a patient to a Minneapolis room and board facility where he assaulted a vulnerable female, placed a former patient — a mentally ill sex offender — at the Anoka Regional Treatment Center alongside mentally ill and developmentally disabled women, and left a mentally ill patient at the wrong homeless shelter in Minneapolis without proper “after-care’’ planning. That patient, Raymond Traylor, also was allegedly threatened by Christensen.

As a result of these and similar breakdowns, judges and attorneys in the state’s mental health courts say they sometimes lack information to accurately assess a patient’s public safety risk.

Service, the former medical director, got a firsthand look at record-keeping lapses when she was hired last year as a contractor to monitor patient files because clinicians were too overwhelmed to complete paperwork. Over an 18-month period through last October, she said, the hospital mailed her as many as 10 patient records a week unsecured on her Edina doorstep. Often, she said, she found them inaccurate and illegible.

“You don’t just ship records off to someone’s house. There was no appreciation of the importance of how to formally assess risk,” Service said. “A lot of them were handwritten notes with mistakes, lists of medications administered that didn’t match other records.”

She said the hospital stopped the practice two months ago, after a DHS administrator in St. Paul learned what the clinicians had been doing.

In an interview, Deputy Commissioner Barry said her agency would have addressed Service’s concerns if she had raised them earlier. “There are clearly more appropriate ways to send records,” Barry said. “We can’t fix problems we don’t know about.”

‘Swelled up and purple’

Confusion reigned in the hallways.

Bill Turnbull, who had received electroshock therapy most of his adult life and was undergoing the procedure once a week, screamed that he wanted to die. Every few minutes he took another run that ended with a sickening thud.

Between 5 p.m. and 10 p.m. that August night, his nurses called the supervising nurse practitioner four times, records show. Each time, she refused to issue a restraint order, even though policy allowed it in an ongoing crisis. In so many words, she said Turnbull could keep banging into the wall as long as he didn’t attack anyone else, reports show.

By dawn, Turnbull’s head was “swelled up and purple,” according to reports, with blood leaking inside his skull. The nurse practitioner later told state investigators when she saw Turnbull the next day, she “did not realize it was that bad” and that she should have ordered the restraints. A staffer told investigators, “With all these new rules, we were under the impression that we are not allowed to go hands on …”

Two nurses were blamed for maltreatment and reported to the state Nursing Board; they have hired an attorney. Their supervisor received a day’s suspension. The hospital was found responsible for maltreatment and fined $1,000 by Jesson.

After reviewing the cases of Turnbull and the patient who suffered a stroke, Jesson ordered the hospital’s “conditional” license status — a sort of probation — be extended through 2014. Barry e-mailed the staff to urge everyone to stay committed.

“We need to remember that we have undertaken a huge change in culture and practice,” Barry wrote. “That doesn’t happen overnight, or in a year.”


  • About the series

    About THE series

    BREAKDOWN, concluding today, examines failures in Minnesota’s mental health system that have left hundreds of psychiatric patients in limbo. Read past segments at

    Sept. 8: Scores of inmates with dangerous psychiatric problems languish in county jails across the state, posing a risk to themselves and others.

    Oct. 26: The rural mental-health safety net is in tatters, leaving hundreds of patients to wind up in hospital emergency rooms and county jails.

    Nov. 23: More than 60 inmates have committed suicide in county jails and state prisons, many of them with disorders that were treatable.

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