A treatment team of psychologists, social workers and administrators is being blamed for the botched release of a violent patient at the Minnesota Security Hospital in St. Peter last year, according to an investigator's report released Wednesday.
The patient was discharged last summer and dumped at a homeless shelter in downtown Minneapolis.
The Minnesota Department of Human Services brought in an outside investigator to unravel the episode. According to the investigator's report, the hospital's "chaotic" conditions also contributed to the lapses.
The investigator concluded that hospital staff responsible for the man's care failed to work in tandem while operating "under enormous pressure" and without any checks and balances, the Star Tribune reported.
The case was the latest in a series of management lapses at the security hospital, which is Minnesota's largest psychiatric facility and home to nearly 400 of the state's most dangerous psychiatric patients. Human Services Commissioner Lucinda Jesson placed the hospital on conditional license status in 2011 after reviewing several cases of patient maltreatment, and Gov. Mark Dayton said the hospital was in "crisis" after he visited in 2012.
The patient's caseworker told the investigator that the August 2012 incident is "not even a particularly egregious example," and that patients at St. Peter "are routinely held in the system at a higher level of care than is appropriate" due to funding delays and a lack of placement alternatives outside the hospital.
"This results in increased cost, loss of relative freedom for the individuals affected, and a shortage of beds for patients who could benefit from a higher level of care," the report concluded.
Deputy Human Services Commissioner Anne Barry, who has been asked by Jesson to take charge of reforming operations at St. Peter, said the findings exposed a broken system that did not put patient care first.
"Every place that the system could have broken down, it did, and there was a bad result," Barry said Wednesday after reading the investigator's report.
Barry said the hospital now has secondary review procedures in place to make sure such an incident doesn't happen again.