An employee at the Minnesota Security Hospital in St. Peter has been cited for maltreatment after administering a powerful antipsychotic against a patient's wishes and then leading the patient to believe it was a milder drug.

An internal report by the state Department of Human Services concluded that the patient, who was not identified, was given a dose of Haldol and was then tricked into believing it was Ativan, an anti-anxiety drug.

The worker was not fired but was warned that a second substantiated case of maltreatment would trigger disqualification from work in the state Human Services system.

The incident, which occurred in January, goes to the heart of concerns that have prompted senior Human Services administrators to order major retraining of hospital staff, officials said Thursday.

"We shouldn't, we can't, ever trick patients," Deputy Human Services Commissioner Anne Barry said in an interview. "We need to ask ourselves, 'Would I want to be treated this way? No.'

"We should congratulate the people who saw this going on [and reported it]," Barry added. "We are telling everyone to report, report and report."

Last week, Human Services Commissioner Lucinda Jesson ordered a "tidal wave of training" in an effort to transform the culture and attitudes of staff and management at the state's largest mental health facility.

Jesson said the agency's human resources director would spend most of her workdays at the hospital in the coming months in order to coach and mentor employees, as well as serve as the commissioner's eyes and ears.

Jesson's directive came hours after agency investigators cited hospital staff for maltreatment in events surrounding the January death of a patient who was brutally beaten in his room by another patient and not discovered for hours. Investigators found that some hospital staffers avoided interacting with patients, instead spending hours at a time in a secured office area.

Jesson has extended the "conditional" status of the hospital's operating license through 2016 as a result of the maltreatment in the death case.

In the January episode, the health care worker admitted to investigators that "not telling the vulnerable adult the truth was probably not in the [patient's] interest." The worker maintained, however, that giving the patient Haldol was a better alternative than resorting to physical restraints.

The patient had previously agreed to take a calming medication during bouts of manic behavior, but objected to Haldol because it was too sedating, investigators found. But when the patient suffered a particularly disruptive anxiety outburst, the health worker deliberately mixed Haldol into the patient's pudding and then lied about it, the report said.

The patient was housed in the hospital's competency restoration unit, a transitional section where patients hospitalized under court order are sent in an effort to stabilize them sufficiently to understand the legal issues they face in pending criminal cases.

"The staff person's action … was not therapeutic conduct and was likely to hinder the ability to trust or have therapeutic relationships with health care providers, now and in the future," investigators said in the report, issued late Wednesday.