State investigating Security Hospital's handling of missing patient, stabbing

State human services officials are investigating the Minnesota Security Hospital's handling of two incidents Tuesday in which one patient was missing for nearly 22 hours and another patient was arrested after allegedly stabbing his mother at a nearby park.

"It's a very unfortunate, very horrible set of circumstances," said Anne Barry, deputy commissioner of the Minnesota Department of Human Services. "At this point, it's clearly too early for us to speculate that there was a relationship [between the two incidents], and we're treating them as coincidental at this point."

Barry said the department may decide to bring in other agencies and state experts to determine whether either incident at the state-run facility was preventable. The outside assessors could include the state Department of Corrections and security investigators at the Minnesota Sex Offender Program, she said. The facility also plans to conduct its own internal reviews.

MISSING PATIENT FOUND

The problems began Tuesday at 1:40 p.m., when a patient, William Pfeffer, left the facility without permission. The 25-year-old, who was committed to the facility after being classified as "mentally ill and dangerous," was wearing an electronic monitor at the time he left.

The monitor alerted employees that Pfeffer was no longer on the facility grounds, but the monitor did not contain any G.P.S. tracking device that would have allowed employees to pinpoint Pfeffer's exact location.

Employees immediately began looking for Pfeffer and set up an incident command center at the facility to coordinate the search within ten minutes, Barry said. Employees called the St. Peter Police Department at 2 p.m. after they failed to locate the patient, she said. The police sent out alerts to community members via text and email three hours later.

Barry said the investigation will look into whether the facility should assist in notifying community members more quickly, but she said the responsibility for community notification rests with law enforcement, not employees at the treatment facility.

STABBING VICTIM IN CRITICAL CONDITION

While the search was under way, at about 3 p.m., another male patient left for a pre-arranged pass with his 69-year-old mother. The patient and his mother headed to Seven Mile Creek Park, a few miles away. About two hours later, deputies responded to a report of a stabbing at the park.

When they arrived, they saw the 48-year-old patient stabbing his mother, according to a statement released Wednesday by the Nicollet County Sheriff's Office.

Authorities arrested the patient and air-lifted his mother to a hospital for treatment. The patient's mother suffered several stab wounds. She remains in critical condition at Hennepin County Medical Center, a hospital spokesperson confirmed.

The man remains in custody at the Nicollet County Jail, pending charges for attempted homicide.

A search team located Pfeffer on Wednesday around noon at nearby Seven Mile Creek Park — about 22 hours after he left the facility without permission. A search team dog traced Pfeffer's scent after a hunter reported seeing someone who matched his description, according to an all-staff email sent by Minnesota Security Hospital administrator Carol Olson. The search dog bit Pfeffer, Olson's email said, and authorities transported him to a local hospital for medical treatment. Barry said the patient will return to the facility later today.

INVESTIGATIONS UNDER WAY

Nicollet County Sheriff Dave Lange said he has no reason to suspect that the two incidents were related, but said state investigators could decide to conduct a further review.

Barry said the state investigations will look at whether employees adequately assessed each patient's risk level and whether the facility should take more steps to increase security. However, she cautioned that any increase in security needs to be balanced against the rights of the majority of patients who follow the rules and are not violent. The facility provides treatment to about 400 adults classified as mentally ill and dangerous. The last time a patient went missing was more than a year ago, Barry said.

"There are usually long periods of time between people who walk away from our campuses, and that's part of our responsibility to make sure that we do everything we can to prevent this from happening," she said.

The incidents come at a difficult time for the Minnesota Security Hospital.

Olson, the Minnesota Security Hospital administrator, sought to reassure employees in an all-staff email sent last night.

"Today we had two very significant events that occurred with patients in our programs," Olson's email said. "In an effort to be transparent and also to keep rumors from running rampant, I wanted to send out this email."

Olson was hired in late March to replace administrator David Proffitt, who was forced to resign after a state-funded investigation found problems with his leadership style. The facility has been under scrutiny from DHS licensing officials who placed the facility on a conditional license in December 2011 after finding inappropriate and excessive use of restraints and seclusion.

Olson's email details employees' efforts to locate Pfeffer.

"I was very impressed with the organized, very detailed search that was completed," Olson wrote. "The only thing that could have gone better is if we would have been successful in finding Mr. Pfeffer."

The email also addressed the alleged stabbing by the patient, who was in the facility's transition program, which helps patients prepare for discharge back to the community. It noted that the patient left for a pass with his mother at about 3 p.m.

"Sometime during the pass, he and his mother had an argument and [he] proceeded to stab his mother," the email said. "This occurred at Seven Mile Creek."

It continued, "[The patient] has been doing very well clinically, he has been going on numerous passes into the community as well as on passes with his mom."

The email closed by noting, "With both of these incidents, we need to continue to support the staff who work closely with these patients, we need to support any patients who have a relationship with these two patients. Keep up the great work you all do each and every day here."

Barry praised Olson's handling of the incidents.

"We are so grateful that she took this position," Barry said. "She is doing, we think, a tremendous job."

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

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