Employee injuries at the Minnesota Security Hospital in St. Peter, state's largest facility for the mentally ill and dangerous, increased sharply this year as the number of permanent psychiatrists dropped from six to one and security practices have put counselors into closer contact with patients.
The number of employee injuries caused by violent patients so far this year has already surpassed the number for all of 2011. As of July 30, the Minnesota Security Hospital recorded 40 employee injuries caused by patient assaults or restraints serious enough to require a report to the Occupational Safety and Health Administration. The facility recorded 32 similar injuries last year.
One full-time psychiatrist oversees the care of nearly 400 patients at the facility, assisted by a rotating group of part-time and temporary employees, most of whom barely know the patients. Internal documents obtained by MPR News show the facility lacks enough doctors to provide coverage to all units. Several temporary employees have also left in recent weeks.
PREVIOUS MINNESOTA SECURITY HOSPITAL COVERAGE
• Facility for the mentally ill risks losing license
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''We recognize the disruption this causes with the unit teams and patient care,'' medical services administrator Bruce Hawkinson wrote in an Aug. 21 email to the facility's nurses on Aug. 21. ''But until we are back on track again with full time psychiatric coverage we need to [do] the best we can [with] the resources we have available."
The spike in injuries situation comes at a time when the Minnesota Security Hospital is trying to recover from the controversial tenure of former administrator David Proffitt, who was forced to resign in March after an independent investigation found he yelled at employees and refused to listen to feedback. The facility also is under intense scrutiny from state licensing officials who have cited it for excessive and inappropriate use of restraints.
Employees at the Minnesota Security Hospital have some of the most challenging and dangerous jobs in the state. The patients at the state-run facility include people who killed family members while psychotic and people kicked out of hospitals because they attacked patients and doctors. Many of the patients suffered trauma and abuse as children and now are struggling with severe mental illness. Many take high dosages of anti-psychotic medications that can cause health problems like rapid weight gain and diabetes. Most patients stay at the Minnesota Security Hospital for years.
"We're the end the line," said Chuck Carlson, a security counselor at the facility for nearly 25 years and president of the local union that represents many of the employees. "There's nothing we can do except try to deal with them."
Carlson said the increase in employee injuries is in part due to a change in treatment philosophy. Instead of locking aggressive patients in their rooms, he said, doctors increasingly ask security counselors to place the patient on what they call a "one-to-one." That means the employee stays within a few feet of the patient at all times to prevent the patient from attacking anyone.
"But the consequence is that the patient tends to attack the security counselor instead of peers," Carlson said.
The facility's changing policies on the use of restraints have also contributed to the increase in injuries, said Anne Barry, deputy commissioner of the Minnesota Department of Human Services, the agency that operates the facility.
Several months ago, the facility stopped using regular handcuffs to restrain violent patients and switched to Velcro restraints. Hospital officials quickly realized that more employees were being injured because it took them longer to apply the new restraints. They have since switched back to using regular handcuffs until they can find a better solution, Barry said.
STAFFING SHORTAGE RAISES CONCERNS
The new medical director, Dr. Steven Pratt, is working 60 to 70 hours a week to address long-standing problems at the facility, according to employees and DHS officials.
Barry, the DHS deputy commissioner, praised Pratt, and said he spends a lot of time on the units talking with patients and staff. Carlson, the security counselor, said Pratt provides extensive care to the facility's most mentally ill and dangerous patients, in addition to treating many other patients who are less sick.
"You've really got to feel for Dr. Pratt because he's covering everything," Carlson said.
The state has hired another permanent full-time psychiatrist, who is scheduled to start in September. Pratt, who used to work at the state hospital in Anoka, has agreed to work at the Minnesota Security Hospital for a maximum of two years, Barry said. However, the state has no plans to replace most of the psychiatrists who left earlier this year in protest of Proffitt's angry and volatile management style.
Instead, the facility will rely on psychiatric nurse practitioners to monitor medications and take over many other duties previously handled by psychiatrists. Right now, only one of those nurse practitioners is a permanent employee, and that person works part-time, according to DHS. Another seven practitioners work full-time, but they are all temporary employees. The facility is also relying on seven psychiatrists from other state-run facilities to fill in gaps in the schedule.
That means most patients no longer see the same psychiatric provider every time, despite complex diagnoses and medication regimes that often include high dosages of anti-psychotics. Carlson, the security counselor, said his unit has worked with three different nurse practitioners in the past six months. Patients don't know who they will be seeing when they show up for an appointment, he said.
"I can't imagine what it's like. I've had the same family practice doctor for 21 years. To walk in and see a different one every time I would assume would suck," he said.
DHS officials say the facility no longer needs as many psychiatrists because many of the patients are stable and only require psychiatric visits once every three months. In addition, Barry said, the importance of psychiatrists at the facility has lessened over the years. Psychiatrists are just one part of the treatment team, she said. Nurses and psychologists also play an important role in patient care, and in many cases, advanced practice nurses can handle many of the tasks that used to be the responsibility of the psychiatrists, she said.
"There would be nothing worse that people coming in and changing things on a regular basis," Barry said. "That would be horribly disruptive to staff, but that's not what's happening."
However, internal emails show that administrators are concerned about disruptions to patient care. An internal document obtained by MPR News shows that even with the extra fill-in staff, the Minnesota Security Hospital is struggling to find enough providers to handle basic coverage for the units. One part-time doctor provides two hours of coverage on Wednesday mornings. Another provider is responsible for a 90-minute shift on Mondays and a two-and-a-half hour shift on Tuesdays.
The facility is also dealing with a longstanding shortage of security counselors, who provide most of the direct care to patients. Carlson, who has worked at the facility for nearly 25 years, worked his first mandatory overtime shift last week. He said some employees work double shifts as often as twice a month.
Barry said the department is trying to speed up the hiring and training process, which often takes six weeks.
"We cannot move to fill positions as quickly as we'd like to," she said. "And we know that we've lost people to other jobs."
Sue Abderholden, the executive director of the mental health advocacy group NAMI Minnesota, said despite the concerns, she thinks Barry and other officials are doing a good job of addressing serious, long-standing issues at the facility. She said the decrease in the number of psychiatrists is not necessarily a problem, as long as the facility hires qualified nurse practitioners. Ideally, she said, patients would always see the same provider, but she said that's not realistic for most facilities.
"With the shortage of psychiatrists and a lack of people wanting to work in an institutional setting, you have to make do with what you can," Abderholden said.
Barry said the facility is always working to improve patient care and will continue to make changes as needed. She said the department is partnering with mental health advocates to create a public website where people can track different performance measures at the facility, including how many patients are satisfied with their care and how often the facility uses restraints. Outside groups will help collect and analyze the data. Barry said she hopes that promotes greater transparency about conditions at the facility.
"I understand that people don't always trust us to tell the story about ourselves," she 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