Medication flub is latest setback for state mental hospital

The Minnesota Security Hospital in St. Peter failed to provide prescribed medications for three mentally ill patients, including one patient infected with HIV, in the latest sign of disarray at the state's largest psychiatric institution.

A state investigation released Thursday found that the patients failed to receive their prescribed drugs for short periods in August and September because of a system glitch in which doctors outside the facility were not notified of expired medication orders. The patient with HIV went 10 days without receiving prescribed drugs for his condition, the virus that causes AIDS, investigators found.

The procedural lapse is the latest in a recent string of incidents at the security hospital, which houses 225 of the state's most dangerous and mentally ill patients. Since January, the hospital has been found responsible for neglect in the bloody killing of one patient, who was beaten to death in his room, and for subjecting patients to hours of inappropriate restraint and seclusion.

Facing sharp criticism from patient advocates and lawmakers, the state Department of Human Services has launched an ambitious effort to clean up systemic problems at the St. Peter facility, including inadequate staffing and staff injuries.

The reforms, which have cost more than $10 million, include the hiring of more than 80 staff, the installation of security cameras in all units, and an ambitious training effort centered on getting staff to engage more fully with patients.

While many of the reforms have yet to fully take hold, the hospital has shown significant progress in moving more patients back into the community and in reducing the use of restraints and seclusion.

"I don't think you can find a health system in this state where something doesn't go wrong. It's human beings that work in these systems," Deputy Human Services Commissioner Anne Barry said in an interview. "The important thing is that we found [the error], we reported it, and we did the right thing — we fixed it."

"If they can't fix it, then they should bring in someone who can," said Edward Eide, executive director of the Mental Health Association of Minnesota. "All the training and mentoring doesn't appear to be making a whit's bit of difference.''

Over the past year, the security hospital has been cited at least five times for rule violations and patient maltreatment. In January, a patient was beaten to death in his room by a fellow patient, and last month investigators found that the hospital subjected one patient to hours of inappropriate restraint and seclusion.

State Human Services Commissioner Lucinda Jesson placed the hospital's license on conditional status as a result of earlier incidents and, in May, extended that until December 2016 — effectively placing the hospital on probation for another two years.

The latest incident involves one of the most crucial roles of a psychiatric hospital: The timely and accurate dispensing of medications.

Tens of thousands of doses of medication are administered monthly to patients at the St. Peter facility. Many are antipsychotic drugs necessary to reduce depressive or aggressive thoughts, and to help prevent mentally ill patients from harming themselves or others.

In July, staff members discovered a "systemic failure" in the process for recording when physicians' orders for medications were set to expire. The system was failing to detect some cases in which doctors who worked on contract for the hospital had ordered medications, but those orders had expired.

The hospital found that one patient who suffered from schizo-affective disorder, which is characterized by mood swings, was deprived of an antipsychotic drug, Clozapine, for four days. Another patient who suffered from antisocial personality disorder went 23 days without an antipsychotic drug, Abilify. The two patients did not notice any change in symptoms and did not appear to be harmed, state investigators found.

However, the situation could have been serious for the patient infected with HIV. The patient took an anti-viral drug, Norvir, as part of a three-drug daily regimen. The patient told investigators that missing doses of Norvir could cause the virus to resist the medication, increasing the risk of infection.

After the hospital reported the lapse, investigators with the Department of Human Services visited the facility in September and conducted interviews with each of the affected patients. The facility was found responsible for neglect and ordered to pay a $1,000 fine. The facility has since corrected the problem, the agency said.

Chris Serres • 612-673-4308