Minnesotans with disabilities continue to face harsh disciplinary techniques, including life-threatening prone restraints and seclusion, despite promises to end such practices in state-regulated facilities.

At a group home in Crystal, for example, a 33-year-old disabled woman was strapped to a restraint chair for up to nine hours a day without food or bathroom breaks, a practice that lasted for months. State regulators did not intervene until last month — more than three years after the home's operator informed authorities of the restraint chair.

Such stark findings, detailed in a 57-page report filed last week by a federal court monitor, are raising new questions about how well the state is monitoring care for the 35,000 Minnesotans with disabilities who receive services through nearly 1,300 state-licensed programs, homes and facilities.

Six years ago, the state came under harsh criticism after reports surfaced that developmentally disabled people in state facilities were being secluded and restrained with handcuffs and leg hobbles for acts as minor as touching a pizza box.

In response, the Minnesota Department of Human Services (DHS) pledged to eliminate the practice — except in emergency cases, such as danger of physical harm — at all state-licensed programs and facilities that care for people with disabilities.

State officials say the use of physical restraints has dropped sharply in the last year and that they are taking other steps to improve care for those with physical and mental disabilities. "This is a massive undertaking and a critical one," said Lucinda Jesson, state commissioner of human services.

Nonetheless, the court monitor found that the practices still persist at community programs and group homes for the developmentally disabled. Statewide, a total of 963 people with disabilities were physically restrained between July 2013 and September of this year. In addition, 40 people were mechanically restrained and 70 were placed in seclusion rooms over the same period, according to his report.

The state has also received reports of 289 people subjected to prone restraints, a particularly dangerous technique in which a person is held facedown on the ground. Prone restraints are banned in state-licensed programs for the disabled because they can lead to serious injury and death by asphyxiation. While use of such restraints has fallen dramatically over the past year, with just one reported incident in September, disability advocates are alarmed that the practice has not been eliminated entirely.

"It is reprehensible that we are still allowing providers to engage in practices that are universally condemned and potentially fatal," said Roberta Opheim, the state ombudsman for mental health and disabilities, who called attention to the excessive use of restraints in a 2008 report.

In an interview, Jesson said she was "appalled" by the report of the woman restrained without food and bathroom breaks, and she has ordered an investigation into why her agency did not intervene earlier.

At the same time, Jesson said, the state has made substantial progress toward phasing out use of mechanical restraints and seclusion. Incidents at state-licensed programs have dropped by about 80 percent between July 2013 and September, according to DHS.

The agency has also launched an ambitious training effort, in which thousands of county and state employees and providers statewide have participated in workshops and online courses on how to provide positive care without the use of restraint and seclusion. Even so, large providers say it can take years to phase out the practices in group homes and programs that help disabled people live and work in the community.

"We are moving as quickly as we can toward what everyone agrees is absolutely the right goal, which is the elimination of restraint and seclusion," Jesson said.

The use of physical restraints has a long and contentious history in Minnesota. As far back as 1949, Gov. Luther Youngdahl burned 350 straitjackets and other restraints in a public bonfire to show his opposition to the "barbarous devices." In June 2013, the Department of Human Services issued a strong statement prohibiting the use of seclusion and restraint for all programs and services licensed by the agency.

Yet some providers have been slow to phase out the procedures, and Gov. Mark Dayton's administration has come under criticism from U.S. District Court Judge Donovan Frank for not moving quickly enough to implement a landmark 2011 settlement that required the state to move disabled people from institutions, such as group homes, to more integrated settings in the community.

Last month, Frank unexpectedly rejected an ambitious state blueprint, known as an "Olmstead plan," for reducing segregation and improving access to community services for the disabled across the state. Frank criticized the plan as vague and lacking measurable goals. He gave the state until mid-November to submit a new one.

In his report last week, federal court monitor David Ferleger, appointed by Frank to oversee the 2011 settlement, wrote: "There appears to be a level of complacency among the state, counties and providers [in] knowing exactly what is going on for [disabled] clients on a day-to-day basis."

In one case investigated by Ferleger, a disabled woman was strapped to a metal-framed wheeled chair — with shoulder, waist and arm straps — an average of 15 days a month and for up to nine hours a day. The woman, referred to in the report as "Karen H.," was not given food or bathroom breaks while she was in the chair, regardless of how long she was restrained. She was also given insomnia medication while strapped to the chair, state investigators found.

Karen H. had a history of self-injury, including ingesting inedible items, but the group home did not limit use of the restraint chair to emergencies. Instead, staff strapped Karen H. in the chair when she exhibited anxiety or symptoms such as "rolling eyes" and "racing thoughts," the court monitor found.

Meridian Services Inc., the Golden Valley-based company that operates the group home, filed regular reports detailing the restraint of Karen H. starting in June 2011. Yet except for one inquiry in 2013, state regulators never questioned the use of the chair, Ferleger found.

"People wouldn't treat their animals like this," said Shamus O'Meara, a Minneapolis attorney representing 300 people with developmental disabilities and their families who sued the state over the use of restraints and seclusion. "But when it comes to someone with a developmental disability, the state didn't appear to care."

DHS did not take action until this summer, and then only by happenstance. In August, authorities discovered Karen H. strapped to the chair while investigating an unrelated incident, the monitor found. Last month, DHS cited Meridian for abuse and neglect and ordered the facility to pay a $2,000 fine and make improvements.

Opheim, the state ombudsman, said the incident reveals a flaw in the way the state investigates incidents of seclusion or restraint. Starting in July 2013, providers were required to file "behavior intervention report forms" documenting incidents of restraint or seclusion. However, these forms are initially sent to the DHS disability services division rather than licensing, which investigates maltreatment, she said.

"The reports appear to be lost in a bureaucratic maze," Opheim said.

Now the department is taking a careful look at how these reports are collected and analyzed. "There clearly was a breakdown here," Jesson said. "It's almost unfathomable what happened, and the situation that this woman found herself in."

The court monitor also highlighted the case of "Andrew L."
Born with cerebral palsy and diagnosed with autism at age 2, Andrew L. began acting violently at the age of 17. He was admitted to the Minnesota Security Hospital, a state mental hospital in St. Peter, which built him a special unit with prison bars to prevent injury to others, according to the court monitor report.

In 2012, Andrew L. was moved to a warehouse-style industrial building in Austin where he lives "a very unnatural form of life," the court monitor wrote. Now 27, Andrew L. is allowed outside only a few times a year and spends about 90 percent of his day alone in his room. When he becomes aggressive, staff are directed to vacate the area and place themselves behind a locked door, the court monitor found.

It costs the state just over $1 million a year to house and treat Andrew L., or $2,740 per day, which includes the cost of paying 17 staff members to monitor him 24 hours a day.

Despite the expense, Ferleger wrote, "Andrew L. leads a lonely isolated life … His life is starkly barren of aspects many people take for granted such as relationships, meaningful daily activities, a job and educational opportunities."

Earlier this year, the monitor determined that Andrew L.'s placement in the industrial building violated the terms of the 2011 court settlement, which required the state to move three developmentally disabled patients from the state hospital in St. Peter to more integrated settings in the community.

While Andrew L. remains at the facility, DHS has moved two other people with developmental disabilities from the state mental hospital to a single-family home in the community. The individuals volunteer in the community, take classes and make their own meals.

"While we have a ways to go," Jesson said, "I have seen real progress toward our goal of moving away from using restraints with people."