The Minnesota Security Hospital in St. Peter failed to adequately supervise two mentally ill residents, resulting in a bloody killing that state officials called “an unacceptable failure” in a maltreatment report released Tuesday.

The state’s investigation into the January murder of Michael F. Douglas, 41, of Mankato, by Darnell D. Whitefeather, 32, has once again exposed deep-rooted problems at the state’s core facility for treating people who are mentally ill and dangerous.

The Minnesota Department of Human Services (DHS), which oversees the hospital, found that staff are reluctant to intervene when residents are violent or disruptive. The hospital that was previously faulted for resorting to punitive methods, including the use of seclusion and restraints, is now being admonished for neglect and a lack of engagement with patients.

“Some staff choose not to be involved and some even elect to spend long hours inside the office, rather than interact with patients,” the inspector general’s report said.

Just eight days before killing Douglas, Whitefeather assaulted another patient at the hospital, breaking the patient’s nose; yet staff determined that Whitefeather did not need increased supervision. Also, on the day of the killing, Whitefeather twice asked to see a psychiatrist, but was told to wait, state investigators found.

Investigators also found that it was likely that 1½ hours passed before staff were aware that Douglas was lying on the floor, dying, in the hospital’s Unit 800, a locked unit where the hospital’s most dangerous patients reside. On the night of the killing, investigators found, there were seven staff members on duty, including five security counselors, serving 14 patients.

DHS Commissioner Lucinda Jesson called the findings surrounding the patient’s death “deeply troubling” and vowed she was going to personally ensure a radical change in workplace culture at the treatment center. Jesson on Tuesday ordered that the “conditional status” of the security hospital’s license be extended until Dec. 22, 2016, effectively keeping the hospital on probation for another two years.

“What’s most troubling is the self-imposed isolation of too many of our staff — not all — who are not mixing with patients,” Jesson said Tuesday. While Jesson said she has witnessed many staff who are committed, “there are far too many who are standing in the way of progress for our patients.”

Jesson said the only way to improve conditions at the hospital, which treats about 220 patients, considered a danger to themselves and others, is to unleash a “huge tidal wave of training and a new infusion of management support.”

To that end, she has ordered that the agency’s human resources director be on site throughout the week to mentor, coach and report where training gaps exist. “We have a segment who aren’t on board yet. Well, get on board or get another job,” Jesson said.

According to a law enforcement complaint, Whitefeather entered Douglas’ bedroom on Jan. 22 and punched Douglas in the face. When Douglas fell to the ground, Whitefeather “stomped” on his head several times. Douglas was later found bloodied and unconscious in his room. Douglas died of head trauma, and Whitefeather was charged with second-degree murder.

Douglas was convicted of murder in 1992, then placed on supervised release in April. He was ordered to the hospital for an evaluation in December.

According to investigators, Whitefeather had a history of violent and aggressive behavior before Douglas’ killing. He was admitted to the security hospital in November 2013 after assaulting a staff person at another facility, and admitted that he had been in approximately 50 fights and that some of the fights were “unprovoked assaults,” according to the state investigation.

On the night of the killing, Whitefeather came to the nurse’s window two times, and asked when he could see a psychiatrist. He was told by a nurse that, if a doctor came to the unit that day, his request would be passed along to the doctor. Otherwise, a psychiatrist was scheduled to come in two days, according to state investigators.

The hospital’s policy stated that staff were to complete patient rounds every hour. However, patients told investigators that staff did not make rounds in the hours the killing occurred.

The state’s investigation into the January killing marks the fourth time that the hospital has been found responsible for patient maltreatment since the end of 2011, when the hospital’s license was first placed on conditional status.

In August 2012, a patient at the hospital repeatedly smashed his head against a concrete wall for approximately five hours while staff watched. The patient’s nurse called the supervising nurse practitioner four times, asking permission for the use of restraint, but each time the supervising nurse refused to issue a restraint order. By morning, the patient’s “entire head was swelled up and purple,” according to a state investigation.

In January 2013, a medical doctor failed to respond to multiple calls about a patient at the hospital who had suffered a stroke. As a result, the patient had to wait four hours before receiving proper emergency medical care, a state investigation found.

Jesson stressed that she did not see staffing levels as an issue surrounding Douglas’ death.

“If someone says we need more staff, I’m willing to listen. But, there was a 1-2 staff ratio at the time of the death — seven employees and 14 patients,” she said. “The issue was that staff were inside the (security) bubble rather than mixing with the patients.”

John Collins, a union steward who has worked at the treatment center for nearly eight years, said managers have put staff in “compromised” situations that he believes endanger everyone.

“We deal with it, cross our fingers and hope like hell nobody gets hurt. Well, guess what, a murder happened,” Collins said.

He said that less than a week before, Whitefeather had broken the nose of another patient on another ward and he was moved to the high-security unit where he was allowed to walk around freely. Collins acknowledged that staff are often staying inside the secured unit station, “because we don’t know what we can or cannot do any longer.”


Twitter: @chrisserres