Internal report finds chronic dysfunction at mental health facility in St. Peter. An internal report found chronic dysfunction at the state security hospital.
A top mental health executive at the state Department of Human Services, Larry TeBrake, has lost his job in connection with long-running security and management lapses at the Minnesota Security Hospital in St. Peter.
An internal report obtained by the Star Tribune describes TeBrake's operation at the Regional Treatment Center as suffering from "overall system dysfunction.'' It describes a workplace lacking in accountability, says employees feared for their safety, and concludes that unstable patients too often were forced into isolation and restraints because of improper staff training.
Sources familiar with the report said those findings, delivered to the commissioner of Human Services last December, laid the groundwork for TeBrake's dismissal.
In an interview Wednesday, TeBrake said he was surprised by his dismissal, and he defended his work over the past year, citing declines in staff and patient injuries and the number of seclusion-restraint complaints. He said working conditions at the hospital, where about 750 employees care for more than 250 of the state's most violent people, had improved significantly.
"Without a doubt, we've been struggling [in the past year],'' TeBrake said. "We've been working hard on changing the culture.'' He said he would continue working at the facility until a replacement takes his place. "I've not been fired, I've been replaced,'' he said.
TeBrake's boss would only say Wednesday that the eight-year director was dismissed because the facility needs "leadership in a new direction ... and new program initiatives needed to be driven by an executive with different skills."
"Over the past year a number of assessments have highlighted the need to look at the structure and performance of the forensic program,'' Mike Tessneer, director of State Operated Services, wrote in an internal memo announcing TeBrake's dismissal.
In an interview, Tessneer acknowledged that the criticisms of TeBrake and his staff, as outlined in the report, had caused serious tensions between the department and labor unions representing employees who feared for their safety while providing care.
Sources said failings at the St. Peter facility were part of a broader pattern of problems in state mental health facilities. A Star Tribune report late last year documented staff assaults and patient injuries at the state's small regional behavioral hospitals, and another article in February described failures by the St. Peter facility to properly track missing patients who violated their discharge conditions while living in community group homes.
TeBrake, 54, who oversaw operations of the security hospital, is a 31-year employee at the regional treatment center and received an annual salary of $108,388.
TeBrake's other responsibilities included directing a state mental health program for young adults and adolescents and community residential support services. That program oversees the supervised discharge of mentally ill and dangerous patients into various communities.
The internal report, submitted to then-Human Services Commissioner Cal Ludeman, described widespread confusion among TeBrake's staff in finding a balance between treatment and security at the St. Peter hospital.
"Staff are committed to caring for some of the most difficult, dangerous, high-needs Minnesotans,'' investigators noted. "Despite the current dysfunction and the ... persistent lack of guaranteed safety, staff come to work every day to care for these individuals. They deserve to feel safe and to know the mission of the organization.''
Other staff comments to investigators included:
• "The organizational structure looks like a bowl of mixed spaghetti, and the left hand doesn't know what the right hand is doing.''
• "We don't have a clear mission and our vision is a moving target.''
• "About four years ago, we did all of that massive hiring. What I clearly heard in that process was: Don't have sex with them, don't let them escape and don't let them get to know you or they'll come to your house and someone will be dead.''
On Wednesday, TeBrake said he might find other duties in the department or seek work outside state government, then reflected on his tenure.
"I've been here a long time,'' he said. "I started out writing behavioral reports for patients. There are a lot of good stories here.''
Paul McEnroe • 612-673-1745
Read about problems at state psychiatric hospitals at www.startribune.com/a311.
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