Two patients at the St. Peter, Minn., facility, were repeatedly abused by staffers. One was forced to sleep on a concrete slab for 25 nights.
Two mentally ill patients at the Minnesota Security Hospital in St. Peter were repeatedly abused by staff members -- including, for one patient, being forced to sleep on a concrete slab for 25 nights -- according to a yearlong investigation by the state Human Services Department.
The abuse, which included isolating the two for extended periods and wrapping their faces in mesh rags, took place in late 2010 and led to a much wider investigation. That examination found evidence that staffers covered up abuses and repeatedly violated isolation and restraint policies.
The latest findings and rule violations, released Thursday, are deemed so serious that the department has placed the hospital's license to operate on a conditional status for two years. In addition, the hospital was fined $2,200 -- the highest amount allowed by state law.
The hospital, which houses 220 of the state's most dangerous, mentally ill patients, who have been civilly committed by judges, has been beset by credibility issues.
"We just didn't meet our standards for providing patients with dignity and appropriate care -- a pattern of not following our own policies," Department of Human Services Commissioner Lucinda Jesson said in an interview Thursday. "This is a culture we are trying to dramatically change."
A doctor still employed at the security hospital is among the staff members who were aware that a patient's mattress had been removed for nearly a month, but did not take any action to return it, the reports state. As a mandated reporter, the doctor was obligated to notify superiors of suspected maltreatment and failed to do so, the report noted.
Regulators would not release the doctor's name, citing privacy laws. However, they did say that the doctor -- hired in 2008 -- would be reported to the state Board of Medical Practice for further review.
Jesson said that none of the employees implicated in the abuse has been fired and that all continue to work at the hospital.
"I cannot undo decisions that were made in 2010 under different hospital leadership," she said. "If it happened today, I'd hold them very accountable."
She said the abuse cases were first investigated at a time when state regulators began to document a chaotic hospital environment where staffers lacked proper training and had little direction from hospital executives on how to care for the state's most dangerous patients.
In an internal report completed last December, regulators concluded that the hospital's daily operation suffered from "overall system dysfunction" and lacked accountability. Those findings set the foundation for firing executive director Larry TeBrake in April, ending his 31-year career at the facility.
TeBrake was replaced by David Proffitt, who ran a hospital in Maine that was fined for unsafe conditions and failure to document staff injuries.
During the investigation, regulators also found a "pattern" of willful violations that characterized the day-to-day hospital operation, Jesson said.
Some residents remained in so-called protective custody for extended periods of time without deciding an end-date for that treatment or how the resident was supposed to achieve a goal that would lead to his release, investigators found.
They cited the case of the patient who was forced to sleep on concrete for nearly a month after his mattress was taken away. That patient was also held for 115 days in isolation. There was no documentation of why the patient was finally released from isolation.
When staff members decided a patient wasn't meeting their standards, they'd implement what was referred to as a "30-day kicker" to hold the patient longer in such a state, to find out whether the patient could maintain proper behavior, investigators found.
In addition, staff used seclusion as a way to stop a patient's verbally aggressive behavior, actions that were not appropriate because staffers were not in imminent risk of physical harm.
In some cases, there was no documentation of a medical professional checking on a patient in seclusion every four hours, as is required, the report noted.
Jesson said she has made it clear to Proffitt that she will not tolerate new, widespread cases of abuse and failures to follow restraint and isolation policies.
"There is more training, less restraint," Jesson said, adding she was "confident" of Proffitt's management since he assumed the job. "He knows very clearly that I will hold him and the staff accountable."
Paul McEnroe • 612-673-1745