A treatment team of psychologists, social workers and administrators at the Minnesota Security Hospital in St. Peter are being blamed for the botched release of a violent patient who was discharged last summer and abruptly dumped at a homeless shelter in downtown Minneapolis.

But the hospital’s “chaotic” conditions also contributed to the lapses, according to an outside investigator hired by the Minnesota Department of Human Services to unravel the episode. The investigator concluded that hospital staff members responsible for the care of Raymond Traylor failed to work in tandem while operating “under enormous pressure” and without any checks and balances. The investigator’s report was released Wednesday.

Traylor’s case was the latest in a series of management lapses at the security hospital, which is Minnesota’s largest psychiatric facility and home to nearly 400 of the state’s most dangerous psychiatric patients. Human Services Commissioner Lucinda Jesson placed the hospital on conditional-license status in 2011 after reviewing several cases of patient maltreatment, and Gov. Mark Dayton said the hospital was in “crisis” after a personal visit in 2012.

Traylor’s caseworker told the investigator that the August incident is “not even a particularly egregious example,” and that patients at St. Peter “are routinely held in the system at a higher level of care than is appropriate” due to funding delays and a lack of placement alternatives outside the hospital. “This results in increased cost, loss of relative freedom for the individuals affected, and a shortage of beds for patients who could benefit from a higher level of care,” the report concluded.

Deputy Human Services Commissioner Anne Barry, who has been asked by Jesson to take charge of reforming operations at St. Peter, said the findings exposed a broken system that did not put patient care first.

“Every place that the system could have broken down, it did, and there was a bad result,” Barry said Wednesday after reading the investigator’s report.

“The first line of control failed, and we didn’t have the proper backup in place. We certainly learned that lesson in this situation, and now secondary review procedures are in place to make sure it doesn’t happen again.”

Planning breakdown

The incident was first reported by the Star Tribune in August after the newspaper obtained documents disclosing hospital staffers were forced to discharge Traylor because they missed a deadline to file a mandatory 60-day progress report with a Hennepin County judge.

Traylor’s release without a proper “aftercare” plan alarmed Hennepin County prosecutors, who said at the time that Traylor “poses a danger not only to the public but also to himself … Mr. Traylor is again on the streets of Minneapolis because someone did not do their job.”

Dayton reacted angrily to the incident, and Jesson hired an outside health care attorney to review the chronology and breakdowns that led to Traylor’s releases. “That anyone would think it’s OK to discharge someone from a state security hospital to a homeless shelter is just fundamentally wrong,” Jesson said at the time.

The attorney’s investigation also highlighted a shortage of resources in Hennepin County to place difficult, mentally ill clients on discharge from the security hospital. Few safe, secure settings are available in the county, which is essentially why Traylor ended up at the Salvation Army’s Harbor Lights shelter on the western edge of downtown Minneapolis, the report concluded.

Traylor’s caseworker, who was responsible for his aftercare plan, told the investigator that he warned the hospital staff just before the release that there were no proper residential settings for Traylor and, as result, he should just be taken to the homeless shelter. That is exactly what happened. But the caseworker then went on vacation, leaving Traylor more or less to fend for himself on the streets of downtown Minneapolis and find his way to the Hennepin County Medical Center to receive antipsychotic medications, the newspaper found.

In addition, the hospital treatment team responsible for Traylor’s release “did not appear to have much familiarity with the various shelters available in the Twin Cities or what services were offered at those shelters,” the report said.

It is still unclear why hospital staff members missed the crucial deadline to file a court report on Traylor’s status — a failure that caught his treatment team off-guard and forced them into the emergency discharge plan.

As a result of the breakdown in logging Traylor’s status, the hospital has put in a rigid monitoring system with multiple checkpoints to ensure the progress reports are not missed, according to the investigator.