Report: St. Cloud Hospital failed to oversee patient who killed deputy

For days before he killed the deputy, Danny Hammond was raving, hallucinating and threatening to kill himself, his family and any men who walked into his hospital room.

Not once during his 72-hour psychiatric hold at St. Cloud Hospital did Danny Hammond see a psychiatrist or the inside of the psychiatric ward. Before his psychiatric hold was up, Hammond wrestled a gun away from Aitkin County Deputy Steve Sandberg, killing the veteran investigator who was standing guard over him at the hospital's request. Hammond died shortly after being tasered by officers responding to the Oct. 18 attack.

On Monday, the Centers for Medicare and Medicaid Services released a report blasting St. Cloud Hospital for failing to provide proper psychiatric care to Hammond, whom staff had consistently described as violent, suicidal and unstable throughout his stay.

Despite that, the report said, the hospital terminated psychiatric care after one day. Last month, the agency placed the hospital on "immediate jeopardy" status and threatened its federal funding until it corrected its policies.

The hospital announced Friday that it had done so and its warning status had been lifted.

In a brief statement, hospital President Craig Broman asked the community to "trust that St. Cloud Hospital is safe." "The patient was evaluated by a credentialed member of our psychiatric team," he said by e-mail. "We have been asked to refrain from commenting on specifics related to the tragic incident. We look forward to providing a comprehensive review for the public when we are in a position to do so."

Hammond — who had attempted suicide after terrorizing his wife at gunpoint — arrived at the hospital comatose after a drug overdose. When he woke, a physician assistant performed a psychiatric evaluation and ordered a 72-hour hold, describing him as potentially violent and dangerous and a suicide risk.

Hammond begged the staff to kill him, tried to smother himself with pillows, and asked one nurse to set him on fire. He hallucinated the smell of cigarette smoke and at one point insisted that his hospital bed was leaking oil.

Staff considered Hammond "a high risk for violence," the report said. Hammond "verbalized that he was going to kill himself and that he wanted to kill his family member for calling 911 and saving him," the report said.

Staff made notes in his file that he was "potentially violent and dangerous. [Hammond] was a flight and a suicide risk." St. Cloud "routinely admits patients with acute psychiatric symptoms to general medical units," the report noted, including "any patient who requires law enforcement presence due to the patient's behavior symptoms or criminal history."

On Sunday morning, Oct. 18, the law enforcement presence was Sandberg, a veteran sheriff's investigator who handled many of Aitkin County's domestic violence cases. Nurses' records noted that Hammond's behavior had been "escalating" throughout the night and that he seemed irritable and agitated.

Hospital staff checked on him throughout the night, and found that "sometimes [Hammond] was sitting on the recliner or the couch, conversing with the police officer."

After 5 a.m., according to the attendant, Hammond started talking about going home. He wanted to get his truck and get back to his house. He mentioned his wife. Sandberg reminded him that he wasn't going home when he was discharged — he was going to jail.

"Shortly after, [Hammond] started walking toward the door, the police officer stood up, [Hammond] charged the police officer and obtained the firearm," the attendant told officials from the Minnesota Health Department, who compiled the report for the Centers for Medicare and Medicaid. "[Hammond] and the police officer struggled, [the hospital staffer] heard gunshots, and all emergency protocols were activated."

To get out of immediate jeopardy status, the hospital pledged to have doctors — not physician assistants — order psychiatric holds from now on. Patients on psychiatric holds will receive psychiatric treatment for a full 72 hours unless a physician and consulting psychiatrist mutually agree treatment is no longer necessary. The hospital also agreed to improve training, communication and documentation among the staff when dealing with suicidal or homicidal patients.

The state Department of Public Safety declined to comment and the Aitkin County sheriff could not be reached for comment.

The full CMS report is here: