The state's largest psychiatric hospital improperly restrained a patient with a history of aggressive behavior early this year — in one case confining the individual for more than 17 hours.
The incident, outlined in a state investigation released Wednesday, suggests that employees at the Minnesota Security Hospital in St. Peter continue to struggle with proper treatment of patients, even after state officials ordered them to reduce their reliance on physical restraints.
Investigators found the individual had been placed in restraints or seclusion 55 times in one month, and faulted the staff for violating hospital rules by failing to release the patient even after criteria for release were met and by failing to counsel the patient for trauma after each incident.
The lapses come as state officials face heightened criticism for the persistent use of restraints and seclusion at state-licensed facilities and community programs for people with disabilities and mental illnesses. This month, a federal court monitor reported finding more than 1,000 incidents of restraint and seclusion of disabled people over a 14-month period. One woman at a group home urinated on herself after being kept in a restraint chair without food or bathroom breaks for up to nine hours a day, the monitor found.
The Minnesota Department of Human Services (DHS), which oversees the St. Peter hospital, pledged a year ago to eliminate the use of restraints and seclusion, except in emergencies, at all programs and facilities licensed by the department. While incidents have dropped dramatically over the past year, facilities that house people with aggressive disorders have struggled to find less punitive measures.
The effort to reduce restraints is particularly challenging at the state security hospital, which houses about 225 of the state's most dangerous and mentally ill patients. There, staff must balance the often-conflicting roles of treating mental illness with stopping patients from hurting themselves and others. In January, a patient was beaten to death in his room — a murder that state investigators later blamed on poor supervision and a lack of engagement among some hospital staff. Because of the incident, the state extended the hospital's conditional license another two years to December 2016.
Deputy Human Services Commissioner Anne Barry said the St. Peter facility has initiated a series of reforms, including mandatory training on how to engage patients positively and de-escalate tense situations, that likely will prevent such a violation from occurring again.
"There is so much observation and coaching and mentoring that it's really hard to believe that we'd see something exactly like this again," Barry said.
Barry also said the use of restraints has dropped sharply in recent months. Patients at the state security hospital spent 31 hours in restraint and seclusion in September, down from 174 hours in February, when the violation occurred.
Sen. Kathy Sheran, chairwoman of the Senate Health, Human Services and Housing Committee, called the report "very frustrating" and said she plans to seek more information from DHS officials at a committee hearing early next month. "There should be earlier interventions so that there will be less need for seclusion and restraint," said Sheran, DFL-Mankato.
Patient advocates, however, worry that state regulators are running out of options. Over the past year, the security hospital has been cited at least seven times for rule violations and patient maltreatment.
If the state cannot produce results soon, it should consider handing the day-to-day management of the facility over to a private entity, said Sue Abderholden, executive director of the National Alliance on Mental Illness (NAMI) in Minnesota.
"Enough is enough," she said.
The DHS inspector general initiated the St. Peter investigation this year after receiving a report of a patient placed in a restraint chair after throwing snowballs at hospital staff. A registered nurse told the patient that the snowball "could be considered a weapon" and issued a warning, according to an incident report. The patient also rubbed one wrist with a piece of ice. Given the patient's history of self-injury, including attempts at choking with clothing, staff determined that a restraint chair was the "most appropriate response," they told investigators, and the patient was placed in the chair for 5 hours.
Investigators ultimately documented 55 cases during February in which the patient was restrained or secluded. Eight of the restraints and seclusions lasted between three and four hours — one more than 10 hours, and another for more than 17 hours, according to the investigation report. On eight occasions, staff recommended electroconvulsive therapy for the patient following the use of restraint or seclusion.
State investigators also found the hospital was not consistent in determining when the patient was to be released from restraint or seclusion.
Barry said she now personally reviews any incident of restraint or seclusion at the hospital that lasts longer than two hours, to better understand the underlying causes.
"This whole interaction [with the patient] would be different today," she said. "We aren't seeing people in restraint chairs in anywhere near the amount of time that we saw" when the violation occurred in February.
DHS officials have given the hospital 30 days to complete a series of corrective actions. These include a review of the facility's policy on seclusion and restraint and a plan to ensure ongoing training.
"It's a challenging environment, but there has got to be a better solution than tying someone to a chair for hours," said Sheila Novak, whose son has been a patient at the St. Peter hospital for three years.