State facility for the mentally ill risks losing license over turmoil

David Proffitt, the administrator of the state's largest facility for the mentally ill and dangerous, began his new job in August 2011 with a vow to improve patient care and reduce the use of restraints and seclusion.

The Minnesota Security Hospital, however, shows few signs of turning around. If anything, some of the problems have worsened and new tensions have surfaced, according to eight employees interviewed by MPR News and previously unreleased state data from the Department of Human Services.

The use of restraints has more than doubled since Proffitt arrived, although DHS officials said a change in reporting methods explains the increase. Employees describe a chaotic work environment made worse by confusing policies and a lack of adequate training. They said the turmoil has alienated employees and led to the exodus of the facility's top psychiatry staff.

In the meantime, the state has hired a private firm to investigate allegations by several psychiatrists that Proffitt created a hostile work environment and made sexually inappropriate comments.

DHS Deputy Commissioner Anne Barry told MPR News the facility is now just a few missteps away from losing its license and being taken over by the U.S. Department of Justice as a result of mismanagement that set in before Proffitt took over.

More on the Minnesota Security Hospital
• Story: Violence, restraints common
• Graphic: Patient injuries in 2011
• Graphic: Time spent in restraint, seclusion

The uncertainty among people who work at the facility in St. Peter, Minn., seems to be increasing, too.

Employees who spoke to MPR News said the current concern among staff was sparked by the firing of psychiatrist Dr. Michael Harlow after an incident in November during which a patient was put in seclusion, placed in handcuffs, and stripped naked.

That particular incident, even against a background of steady tumult, is repeatedly cited by staff as disorienting and paralyzing when it comes to everyday practices. Employees said they no longer know how they are supposed to respond to patients who are suicidal or homicidal. Instead, they said they're left debating the meaning of confusing policies and worrying about getting fired, while patients wield weapons and threaten violence.

That uncertainty led to another violent incident on one of the units in late January that escalated to a hostage situation, employees said.

"I don't know what I'm supposed to do," a longtime security counselor told MPR News. "I don't know what my job is. We know that there's a lot of pressure going on, so we're all scared because we don't want to get fired."

Five of the employees asked that MPR News not publish their names because they feared they would be fired or sued for talking to the media. They include security counselors and medical staff.

A letter written by facility psychiatrists and given to DHS Commissioner Lucinda Jesson on Dec. 30 said, "From one day to the next, staff has not been sure who is in charge of whom, With the firing of Michael Harlow, which came out of the blue... the campus is in an uproar and the staff are terrified."

A DIFFICULT JOB

The Minnesota Security Hospital occupies a two-story brick building on a sprawling campus in St. Peter, about 70 miles southwest of the Twin Cities. A staff of roughly 800 security counselors, therapists, psychiatrists, social workers, nurses, and others provides treatment for nearly 400 patients in the hospital and nearby transitional facilities who have been deemed mentally ill and dangerous. Most patients have lengthy criminal records and many have been the victims of childhood physical and sexual abuse. Some are awaiting trial for murder and other violent crimes.

As one security counselor put it, "If you read in the paper where somebody chopped their mom's head off and were committed to the hospital instead of going to prison, they're here."

The facility provides psychiatric treatment and therapy. The average stay for a patient is eight years.

It can be a scary place to work, even when the facility is operating smoothly. One employee said, "We have patients out there with HIV and AIDS, and when they get pissed off at us, they bite their cheeks, make themselves bleed, and spit blood in our face."

It can also be a scary place to be a patient. Last year, the facility recorded 310 patient injuries. Nearly one in five was caused by a patient-on-patient assault, according to data provided to MPR News by DHS. The list includes head injuries, bruises, and bloody lips, tongues, and noses. One patient was stabbed with a pen. Another was kicked in the jaw.

Patients have also been injured when in restraints or seclusion — and it's those types of incidents that have attracted the most attention at the Minnesota Security Hospital in recent months.

Employees are supposed to use restraints or seclusion only when a patient is at serious risk of harming himself or someone else, and all other interventions have failed.

A DENIED REQUEST LEADS TO VIOLENCE

Security counselors said the evening of Nov. 15 started out like any other on Unit 800 — the facility's treatment area for male patients who are either new to the facility or in a mental health crisis.

While most patients prepared for bed, one patient asked to be taken to the canteen. When an employee said the canteen was closed for the night, the man began throwing chairs, according to interviews with security counselors, Harlow, and a newly released 38-page DHS report.

Document: Read the DHS report on the Minnesota Security Hospital.

The situation escalated quickly. The patient grabbed a green plastic chair and slammed it repeatedly against a window. Staff tried to calm him down and he agreed to be placed in seclusion in his bedroom.

Later that night, the man began cutting his arms with plastic shards from a broken marker. He pushed his mattress up against his bedroom door so the staff couldn't see inside. He threatened to rape and kill a nurse.

Security counselors said they feared the man was harming himself.

With the mattress blocking their view, they could no longer follow the facility policy that requires staff to provide nonstop observation of patients in seclusion. They felt stuck and out of options.

Dr. Harlow, a staff psychiatrist who had worked at the hospital for nearly three years, was on call. Harlow said he was worried the patient could have been hiding weapons or considering using his T-shirt or pants to hang himself. Harlow told employees to enter the room and remove the broken marker shards, the mattress, the patient's clothing and everything else.

The counselors handcuffed the man, removed his belongings and used scissors to cut off his clothes.

They looked for a special "tear-proof gown" the facility uses for patients who are suicidal. But the unit was out of gowns, and by the time an employee found one, the patient refused to step back from his door so that staff could safely hand it to him.

The patient stood in his room, naked and screaming, for more than an hour. His mattress was returned nearly two hours later. He was released from seclusion the following day.

The patient said "this incident has brought up trauma from his past and he has had a nightmare about it," the DHS report noted.

A CONFUSING RESPONSE

At this point, many facilities around the country would have conducted an extensive debriefing of all staff members involved, in keeping with best practices. National studies show that the facilities that are the most successful in reducing restraint and seclusion use incidents like these to help learn how to approach violent or upset clients differently the next time.

"That's the most critical," said Dr. Joan Gillece, who oversees a federal program to reduce the use of restraints and seclusion in hospitals around the country. "You can't leave the staff out there by themselves."

Some facilities have gone further and analyzed hospital reports to look for trends. One facility found employees most often used restraints on weekends in the early morning hours, Gillece said. Administrators realized that patients were angry because the staff woke them up at 6 a.m. but made them wait more than two hours for breakfast. The facility changed its practice to allow patients to eat breakfast right after they woke up, and the number of situations involving restraints immediately dropped.

That kind of followup did not happen after the incident at the Minnesota Security Hospital, according to security counselors and Harlow. No one interviewed by MPR News described having any in-depth conversations with supervisors about what happened.

Two security counselors involved in the incident said they still have not received a clear explanation about what they should have done instead. The first time they spoke about it at length, they said, was when DHS investigators arrived a few days later and began asking questions.

As word of the confrontation spread, security counselors on other units said they were equally confused about how Proffitt wanted them to handle violent situations.

"Staff are more than willing to work along with whatever master plan he has because we all want to keep our jobs, but we're being put in a situation where we do what's right but we're still getting in trouble for it," one security counselor said.

Proffitt disputes this account. He said he is aware of several employees who were debriefed by supervisors after the incident. However, he acknowledged that he did not keep track of whether staff members had been debriefed.

Proffitt also said he did not meet with any of the staff members involved, other than a brief meeting to fire Harlow, and did not talk to the facility's psychiatrists about what happened.

A CONTROVERSIAL FIRING

What happened next differs depending on whom you ask. Barry, the DHS commissioner assigned to help resolve the facility's licensing issues, said Harlow was fired because he inappropriately used restraints and seclusion. Barry said Harlow failed to write an order authorizing the use of handcuffs to restrain the patient. However, the facility manual provided to MPR News by DHS says that handcuffs are not considered to be restraints.

"We just need to be very clear that we will no longer allow anyone, staff or ... psychiatrists, to work in such a way that they aren't complying with our policies around restraint and seclusion," Barry said.

Proffitt said the decision to fire Harlow had nothing to do with restraints or seclusion. Staff could have done more to prevent the situation from becoming violent, he said, but once things got out of control, they had no choice but to restrain the patient. However, he said staff should have returned the patient's clothes more quickly.

"He was maintained in a dehumanizing condition for hours without clothing, without [a] blanket, without a mattress, without a pillow, even though it was documented he was trying to sleep on the slab and was calm and quiet," Proffitt said. "Those are things that are not common for this facility. They're not acceptable for this facility."

Proffitt also told MPR News that although he made the final decision to fire Harlow, he acted on the recommendation of a four-person workplace incident review committee.

Dr. John Wermager, who served on the committee and was the facility's director of psychiatry at the time, said that is inaccurate. He said that committee did meet, but did not make any recommendations.

"Michael's dismissal came as a surprise to me, based on how that meeting ended," Wermager said.

Harlow said he handled the situation properly.

"We followed standard operating procedure from the beginning to the end of the incident," Harlow said. "The patient was not injured, and we prevented him from injuring himself and attacking other people. And so, in a nutshell, we did the right thing at the right time, and we kept everyone safe."

CONFUSED STAFF TURN TO POLICE FOR HELP

In recent weeks, employees said they have been trying to interact with agitated patients as little as possible, to avoid making a wrong move for which they could be fired.

Two security counselors told MPR News the confusion over the facility's changing policies on restraints and seclusion led to a frightening incident on Jan. 25 during which a patient took three other patients hostage with a homemade weapon.

Earlier that day, security counselors said, they noticed that a male patient was agitated. He began threatening other patients on the unit. The counselors considered asking to have the man placed in seclusion, but worried they would get in trouble. Instead, they said, they tried to calm the patient by talking to him. Their efforts failed.

According to a police report, the patient, armed with a weapon made out of a broken CD and a pen, told staff he was going to kill them and take several patients hostage. Three patients sat in chairs behind the patient and agreed not to move. Staff called the St. Peter Police Department for help.

One of the officers then pointed his Taser at the patient and ordered him not to move, while the other officer handcuffed the patient from behind. The officers searched the patient and when they did not find any other weapons, they released him to facility staff. No one was injured.

When asked about the incident, Proffitt said he was familiar with what happened, but his response raised questions about how the facility tracks serious incidents.

"The St. Peter Police Department responded in an outstanding manner, came on the unit, explained the options to the client," Proffitt said. "The client then agreed to put down the weapon and to go into the seclusion room."

Asked about the officers' decision to handcuff the patient and threaten to use a Taser on him, Proffitt said, "I don't believe that's true."

Proffitt said he was unaware of the police report.

"I did not see that," he said." "If it is reported, I didn't get it, but that's irrelevant from my perspective."

Proffitt said that when patients have a weapon, employees are always instructed to call the police.

"It's the best outcome we could've hoped for a bad situation," he said.

Employees disagreed. "You want to talk about psychologically harming a patient?" one security counselor said. "What's more disturbing than a cop threatening to tase you?"

A FACILITY UNDER PRESSURE TO MAKE CHANGES

The latest tension at the Minnesota Security Hospital comes at a stressful time. Two days after Harlow's firing, the Department of Human Services placed the facility on a conditional license after finding inappropriate and excessive use of restraints and seclusion dating to 2010, before Proffitt was hired. In one case, they found employees forced a patient to sleep on a concrete slab for 25 days.

The report cited outdated and confusing policies and a lack of staff training. Now the facility must change its policies on the use of restraints and seclusion or risk losing its license. It submitted updated policies to DHS for approval last week.

"When a hospital is operating on a conditional license, you have to make big changes or that hospital will close," said Jesson, the DHS commissioner. "We had no choice but to make big changes."

Earlier this month, DHS secured emergency authorization to fund training for staff on how to de-escalate crisis situations. Several employees began that training two weeks ago.

"I cannot stress enough how urgently this training is needed," said Barry, the DHS deputy commissioner.

DHS also brought in psychiatrists from other state-operated facilities to replace the doctors who left. They plan to hire permanent replacements soon.

State officials updated lawmakers on their progress at a committee meeting Feb. 21.

Roberta Opheim, the state ombudsman for mental health and developmental disabilities, told lawmakers that leadership at the facility have created a crisis situation by not addressing problems earlier.

"Change doesn't come easy, and when you are at the lowest point and recognize the need for change, there will be chaos," she said.

Proffitt sasid he believes the facility is moving in the right direction.

"Most of our staff are excited about our future and where we're going, and [are] very passionate about providing quality care to the patients we serve," he said.

AN ONGOING INVESTIGATION

DHS officials said they are withholding comment on Proffitt's job performance until the investigation into allegations that Proffitt created a hostile work environment has been completed.

The investigation includes allegations that Proffitt made sexually inappropriate comments to employees, according to Barry, the DHS deputy commissioner. She declined to provide any other details.

"When you ask me questions about David Proffitt, I'm not saying if he's absolutely in the clear or not," said Commissioner Lucinda Jesson. "We have an investigation. I'm awaiting the outcome of that investigation, and I take hostile work environment allegations very seriously."

The allegations surfaced at a Dec. 30 meeting between Jesson and several psychiatrists who have since left the facility, Jesson said.

The psychiatrists gave Jesson a letter calling Proffitt's hiring "the most recent, and most destructive, in a long line of administrative decisions that have resulted in the complete disenfranchisement of psychiatry and medicine at the Minnesota Security Hospital."

Proffitt declined to comment on the allegations.

Harlow said his fellow psychiatrists, none of whom agreed to discuss the situation publicly, felt bullied and intimidated.

"It's a very difficult job, but the tragedy about all of this as far as the psychiatrists leaving is there was a group of extraordinarily gifted, extraordinarily dedicated professionals that felt they had to leave because they lived in daily fear of losing their medical licenses on account of David Proffitt's abusive and toxic mismanagement," Harlow said.

Jesson and Gov. Mark Dayton traveled to the facility Feb. 8 to meet with staff and administrators. During a phone interview after the visit, Dayton was asked whether he thought Proffitt was the right person for the job.

"I don't know," Dayton said. "That's for Commissioner Jesson and her team ultimately to make that decision. I don't know enough about him or the situation to be able to give a qualified answer."

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 Minn. 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

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