State licensing investigators decided Tuesday not to cite the Minnesota Security Hospital for maltreatment for allowing a delusional patient who stabbed two people in the face with pencils to keep the weapons in his room.
Last year, the male patient attacked a roommate so severely that the victim needed emergency surgery to remove a three-inch piece of pencil from his nose. An employee rushed to the room to restrain the attacker. "There was blood everywhere," the victim later told investigators.
Clinicians allowed the patient to have that pencil even though the patient had been committed as "mentally ill and dangerous" 14 years earlier for stabbing someone else with a pencil. The victim of the second stabbing said the facility should have told him that the patient had once stabbed someone's "eye out" before he became the man's new roommate.
The Minnesota Security Hospital, which provides treatment to more than 400 adults deemed mentally ill and dangerous, has been at risk of losing its license for two years. Patient injuries are common and doctors are scarce. In 2011, the facility recorded 310 injuries. It has two full-time psychiatrists and relies heavily on nurses and a rotating group of part-time, temporary psychiatrists to provide treatment to some of the most mentally ill people in the state.
State Legislative Auditor James Nobles has previously criticized the state-run facility for not having enough psychiatrists. Most patients do not see a psychiatrist every month and some go three months without doing so, Nobles said in a February report. The patient who stabbed his roommate may have gone months without seeing a psychiatrist, according to the licensing investigation.
The review of the stabbing incident lasted more than a year and found "inconclusive" evidence as to whether the facility or employees neglected either patient. DHS deputy commissioner Anne Barry said she will review the report.
Licensing investigators work for the Minnesota Department of Human Services -- the same agency that runs the facility. The licensing division does not have enough employees to investigate every allegation promptly and delays are common, DHS Inspector General Jerry Kerber said in 2012.
The Minnesota Security Hospital, which provides treatment to more than 400 adults deemed mentally ill and dangerous, has been at risk of losing its license for two years. Patient injuries are common and doctors are scarce.
This year lawmakers approved funding to hire eight additional workers. Once those workers are hired, the department will have about 28 employees to handle nearly 1,000 maltreatment allegations annually.
PATIENT CLAIMS 'ENTRAPMENT'
The attacker, whose name has not been released, has a diagnosis of paranoid schizophrenia and antisocial personality disorder. He was committed as mentally ill and dangerous after stabbing an inmate with a pencil at another facility in 1998, according to the licensing report.
The patient told investigators that he stabbed the inmate to ward off "homosexual advances."
While at the Minnesota Security Hospital, the patient received anti-psychotic medication and appeared less delusional and paranoid. His regular psychiatrist left in January 2012, and it's unclear from the report whether the patient saw a new psychiatrist before the stabbing. The licensing report appears to indicate the patient was seen by an advanced practice nurse practitioner instead.
On April 25, 2012, a clinician met with the man and found he was "doing well with no conflicts with staff or peers" and should see a psychiatric provider again in three months. The patient was doing so well that he was on "level 5," which meant he "had the highest level of privileges" and was "allowed to keep items such as pencils."
But in the week prior to the second pencil stabbing, the patient's condition deteriorated, according to medical records and interviews with four employees referenced in the report.
On the morning of May 11, 2012, the day of the stabbing, the patient's treatment team discussed moving the patient to a "more secure area" because his condition was not stable, but they decided against it because the man was taking medications as prescribed and wasn't threatening anyone.
An advanced practice nurse practitioner saw the patient that day, prescribed two new medications, and described the patient's condition as "one week of increasingly manic-type symptoms, including pressured speech, racing thoughts, decreased sleep, increased energy, irritability, inflated self-esteem, and flight of ideas." The report does not say whether it was the same clinician who saw the patient three weeks earlier.
Later that day, an employee asked the roommate whether he noticed any changes in the patient, and the roommate said no. The roommate later told investigators the patient threatened him about two weeks before the stabbing but he didn't tell anyone because he did not want to move to a new bedroom.
Shortly before 5 p.m., the roommate was resting on his bed when the patient suddenly appeared and "immediately started punching" him. The roommate said his nose "felt funny" but he didn't realize right away that there was a pencil stuck in it.
The victim was rushed to a Mankato hospital and later to Hennepin County Medical Center in Minneapolis for emergency surgery. He returned to the facility the next day.
The attacker, identified in the report as VA1, was moved to a "higher security unit" after the stabbing. The patient told investigators that he harmed his roommate because he confused him with someone else who was trying to steal his belongings. He blamed the facility for not doing enough while he was sick to prevent him from hurting others.
"VA1 stated that the doctors and staff persons knew that VA1 had pencils and knew what was happening," the report said. "If safety measures would have been in place, VA1 would not have gotten in trouble. VA1 stated that the staff persons reacted quickly to the situation and VA1 felt like it was 'entrapment' because they wanted to keep VA1 locked up."
A Minnesota Security Hospital doctor "did not know the last time a psychiatrist saw" the patient, the report said.
Another unnamed employee, identified as SP5, told investigators "that the patients' psychiatric needs were being met at the time of the incident but there was a time prior when several psychiatrists stopped working at the facility and the patients' needs were not being met," the report said.
The employee said "the facility had a triage system where patients with the highest needs were seen first. SP5 stated that VA1 was not one of those patients at the time."
Investigators concluded that because clinicians tried to improve the patient's mental health before the stabbing, "there was not a preponderance of the evidence whether VA1 or VA2 were provided with care or supervision that was reasonable and necessary to maintain their safety."
Sue Abderholden, the executive director of the National Alliance on Mental Illness of Minnesota, a mental health advocacy group, said she agrees with the findings. "There weren't any real big red flags that came up for me," she said, adding that even if the patient hadn't been allowed to have pencils, another weapon could have been used.