Investigation shows complexity of caring for the state's most violent and mentally ill adults


A state licensing investigation has found a patient at the Minnesota Security Hospital in St. Peter suffered maltreatment when he was left naked in his room for about an hour after he violently threatened to rape and kill employees.

The Nov. 15, 2011 incident has been the subject of scrutiny for months and led to the firing of psychiatrist Michael Harlow in December. The firing outraged other doctors at the state-run facility for those ruled mentally ill and dangerous--and sparked an exodus of most of the facility's top psychiatric staff earlier this year. Harlow and other employees involved in the incident said they did nothing wrong and acted to prevent the patient from hurting himself and others.

The decision, made public this week, found the facility and Dr. Harlow violated licensing standards, but that the violations were not serious or recurring. The case sheds light on the complexity of providing treatment for some of the state's most violent and mentally ill adults at a time when the Minnesota Security Hospital is already under scrutiny for its handling of patients.

The facility has been ordered to pay a $1,000 fine. Harlow, who now works at the Hennepin County Medical Center, said he plans to appeal the decision. Department of Human Services Deputy Commissioner Anne Barry, who approved of the decision to fire Harlow, said she was surprised the licensing division did not classify the violation as serious.

"There are human rights violations there," Barry said.

The Minnesota Security Hospital has been operating under a conditional license since December, when an investigation found inconsistent policies on the use of restraints and seclusion. It was ordered to make changes to prevent maltreatment. Any additional violations could result in the revocation of the facility's license and force DHS to find another home for the facility's nearly 400 patients.

DHS Inspector General Jerry Kerber said the latest violation would not jeopardize the facility's license because it happened before the December order. He called the incident ''a complicated case'' and noted the facility has offered more training to employees and is revising its policies on restraints and seclusion.

However, serious concerns remain. There have been 53 reports of problems at the Minnesota Security Hospital since January 1, including several allegations of maltreatment that remain under investigation, according to Kerber. Compared to other facilities, Kerber said, ''that's a high number.''

The licensing finding also comes as the Minnesota Security Hospital tries to recover from months of turmoil under the leadership of administrator David Proffitt, who was ordered to resign in March after an investigation found he yelled at employees, refused to listen to dissenting views, and made comments that employees considered threatening.


The details of the investigation, recounted in a 13-page memorandum released by the licensing division, show that when a patient turns violent, employees often have just a few seconds to make critical decisions.

The patient involved in the November incident, whose name has not been released, had been committed as mentally ill and dangerous due to ''prolonged episodes of violent behaviors that included destroying property, threatening staff members and peers, making weapons and reporting violent fantasies of rape and murder of female staff members,'' according to his treatment plan.

His diagnoses included sexual sadism, anti-social personality disorder, and borderline personality disorder.

The November incident began when facility employees denied a patient's request to go to the canteen outside of regular hours. The patient became ''highly physically and verbally agitated, hurling chairs, and smashing chairs'' and threatened ''to rape and murder'' a nurse, according to the memorandum.

The nurse consulted with Harlow, one of the facility's psychiatrists, who authorized employees to place the patient in seclusion to prevent him from acting on his threats. The patient went into his room and employees locked the door. Then, the situation got worse.

The patient started to shred his mattress and pillow. He used a marker to scrawl death threats on his body. He started cutting his arms with a small object--employees thought it was a plastic shard from a ripped-up marker. The patient later told investigators it was a piece of his watch.

Next, he pushed his mattress up against his door, blocking a window that employees are required to use to observe patients in seclusion.

Harlow ordered employees to enter the room, restrain the patient, remove his mattress, and take off his clothing to check for weapons. They planned to give the client a special ''tear-proof gown'' to wear until he calmed down. Harlow said he worried that the patient would tear up his regular clothing or use it to create a noose.

Several employees entered the room, armed with a plastic shield to fend off an attack. They quickly handcuffed the patient and removed his clothing, his mattress, and everything else they thought he could use as a weapon. An employee later told investigators the patient had jammed his socks full of ''little pieces of fork tines,'' the investigative memorandum said.

Meanwhile, an employee went to grab the unit's tear-proof gown. It was missing. With the patient screaming death threats, bleeding, and lying face down on the ground in handcuffs, the team made a quick decision. They didn't know how long it would take to find the gown. They did not want to leave the patient in handcuffs much longer.

''It's not like we had a ton of options,'' said one of the security counselors involved in the incident, who asked that MPR News not use his name because he said supervisors have warned employees that they would be fired if they talked to reporters.

The employees removed the handcuffs from the patient and left him naked in his room. An employee found a gown on another unit a few minutes later.

But how would they give the patient the gown? To those who don't work at the facility, the answer might seem obvious--open the door and hand it to him. However, the patient was still threatening to attack and kill anyone who entered and had pressed his body up against the door. Every room entry, employees told MPR News, increased the chances that someone would be injured. They nixed the idea.

There was another option. They decided to try to pass the gown through a tray slot in the patient's door. The opening is five inches high and 17 inches wide, and nurses often use it to pass medications to patients.

The method is safe, as long as the patient agrees to step back from the door, said security counselor Chuck Carlson, who is also the president of the local union that represents many of the facility's employees. Carlson, who was not involved in the November incident, said he is aware of at least two employees who have been seriously injured when a patient reached through the opening.

The team asked the patient to back away from the door. At first, he refused, but about 45 minutes later, he relented, and employees passed the gown through the tray. The patient appeared calmer, employees told investigators. He requested his mattress, a blanket, and his medications so he could go to sleep. An employee provided the medications and a blanket, but Harlow refused to return the mattress, even when he walked past the patient's room and saw him resting quietly on the concrete floor.

Harlow said he wanted to give the patient more time to calm down. If the patient got his mattress back and was still agitated, Harlow said, he probably would have pushed the mattress up against the window again.

The doctor left the facility and asked employees to call him later that night with an update. A few minutes later, an employee returned the mattress and the patient went to sleep.


Licensing investigators focused on how long the patient was left naked and without a mattress.

''It was not reasonable or necessary to leave the (patient) naked for appropriately an hour and to withhold the mattress for approximately two and a half hours,'' the memorandum said.

Investigators dismissed concerns about the patient assaulting an employee through the tray opening.

''From our perspective, the door could have been left open as a sign that they wanted to give the guy some clothing, and somehow or other, they could have managed to get through that door without their being a staff injury,'' Kerber, the DHS Inspector General, said.

The investigation found the incident was not serious because the patient was not injured. However, the patient told investigators the experience was ''degrading'' and brought up terrifying memories of being sexually abused in the past.

Kerber acknowledged that facility employees might not agree with the findings.

''I certainly understand how people out there in the field who are dealing with these heated incidents at the moment see some people in St. Paul sitting in an office second guessing the decisions they made at the time, and certainly we take that all into account,'' he said.


In recent months, the facility has offered more training for employees. Much of the training focuses on how to work with violent patients who have also been the victims of abuse. The approach is called ''trauma-informed care.''

Barry, the DHS deputy commissioner, said the training teaches employees how to identify situations that might trigger memories of abuse and learn how to better empathize with patients.

Barry remains critical of how employees handled the November incident. She said she does not object to the decision to restrain the patient, place him in seclusion, and temporarily remove his mattress. Her concerns, she said, are based on what happened before and after.

She wonders if employees could have done more to help the patient calm down.

''There's things we need to look into early on as to how a client escalated to the point of threatening to kill someone,'' Barry said.

She also believes the employees should have returned the mattress sooner. ''That's the punitive part of this,'' she said.

Barry hopes the planned redesign of the facility will also reduce violent incidents by widening narrow hallways and eliminating ''hiding places'' in stairwells. She said the redesign team will also consider whether it needs to make smaller changes, like altering the tray doors so that employees can pass items through without the risk of assault.

The renovation will likely take several years. The state legislature authorized only a fraction of the total amount requested by DHS to fund the project. The facility received $3.7 million to cover pre-design and design of the first phase of the renovations.

''It can't happen as quickly as we'd like it to happen,''Barry said.

Hospital at Risk:
Danger and Dysfunction at the Minnesota Security Hospital
State facility for the mentally ill risks losing license over turmoil
―Published: Feb. 28, 2012
Data: Violence, restraints common at Minnesota Security Hospital
―Published: Feb. 28, 2012
David Proffitt, head of Minnesota Security Hospital, resigns at state's request
―Published: March 27, 2012
Former Minn. Security Hospital leader's 'extremely assertive' style rankled some
―Published: March 28, 2012
State failed to review troubled past of ousted Minn. Security Hospital administrator
―Published: March 30, 2012
Auditor to look at agency's hiring practices in wake of Proffitt dismissal
―Published: April 2, 2012
Former Security Hospital head still getting paid
―Published: April 12, 2012
After complaints, MN Security Hospital inspected
―Published: April 13, 2012
Plan gives DHS more oversight in state mental health services
―Published: April 20, 2012
Funding for St. Peter hospital renovations in doubt
―Published: April 27, 2012
Security hospital worker 'emotionally abused' patient
―Published: May 1, 2012
Security Hospital in line for fraction of funding request
―Published: May 4, 2012
State investigating Security Hospital's handling of missing patient, stabbing
―Published: May 9, 2012
Investigation shows complexity of caring for the state's most violent and mentally ill adults
―Published: June 8, 2012
DHS confirms resignation of executive
―Published: Aug. 23, 2012
More injured employees, fewer doctors at Minnesota Security Hospital
―Published: Aug. 29, 2012
Minn. moves mentally ill patients to avoid legal action
―Published: Dec. 14, 2012