Video (59:17) : Burt Ewing Jr. murdered his sister in 1998. After a judge found him not guilty due to mental illness, he was committed to the Minnesota Security Hospital in St. Peter. 12 years ago, he stabbed his mother while on a "day pass" from the hospital. He was found not guilty for attempted murder and will remain at the security hospital indefinitely.

Nobody stopped Bill Turnbull the night he turned himself into a battering ram and slammed his head repeatedly into a concrete wall.

Nurses and aides at the Minnesota Security Hospital stood and watched — in fear for Turnbull’s life, but also in fear for their jobs if they dared to intervene. A state hospital once infamous for the overuse of patient restraints was now under new rules. To restrain Turnbull, they would need permission from their supervisor. But when they called her at home, records show, they were turned down repeatedly, and his ordeal went on until dawn.

The events that unfolded that night in August 2012, detailed in licensing reports and other documents, reflect breakdowns in patient care that continue to shadow the state’s largest psychiatric hospital, Minnesota’s core treatment facility for the mentally ill and dangerous.

Nearly two years after the hospital’s professional psychiatric staff departed in a mass resignation, the state still has not hired a full complement of psychiatrists, documents show. Basic medical record-keeping has been neglected, employees have been placed in danger and patients have been discharged with inadequate safeguards, according to internal memos, federal records and agency files reviewed by the Star Tribune.

Dysfunction at the hospital, a sprawling facility that houses more than 300 patients on the outskirts of St. Peter, Minn., has rippled through the state’s mental health system, contributing to backlogs in patient care and delays in court placement of the mentally ill. “The hospital infrastructure to care for the most sick and most dangerous people in Minnesota is broken,” said Dr. Jennifer Service, who resigned as the hospital’s medical director in 2012.

Top officials at the state Department of Human Services (DHS), which operates the hospital, say they’re making progress, rebuilding the staff and changing the culture. Over the past four years, they note, more than 130 patients have been discharged and only 24 were ordered back by a judge, an indication of successful treatment. This year, 48 patients were discharged, records show.

Bedrooms in the men’s admission and crisis wing of the Minnesota Security Hospital in St. Peter are considered to have the highest security.

“We’ve made some progress, but every time something isn’t done in an exemplary way, we’ll report it,” said Deputy Commissioner Anne Barry, who now oversees reforms at the hospital. “The leadership feels strongly about accountability.”

Barry says her mandate is to restore public confidence that Minnesota’s most challenging mental health patients will receive the care they deserve and have realistic hopes of being discharged into stable living arrangements. “We want a more therapeutic environment, and we want to work on getting more capacity in the communities so that they have stable places to live,” Barry said. “We are showing that people can recover and they can move on. For a long time we were not moving.”

Even so, a Star Tribune review of patient records, along with more than a dozen interviews, shows lingering problems.

• The hospital has been hobbled by turnover and resignations. In the psychology unit, for example, turnover has averaged 25 percent annually since 2009, records show, and of the 15 doctorate-level psychologists on staff, eight were hired in the past two years. At least 20 have resigned since 2006. Currently the hospital has just one full-time, on-site psychiatrist, and that official, Dr. James Christensen, is not board-certified in forensics, DHS acknowledges. Nurse practitioners perform much of the psychiatric care.

• Staff turnover and unclear mandates have made it a dangerous workplace. Staff injuries rose nearly 50 percent between 2011 and 2012, most of them involving assaults by patients. They have fallen this year, but the hospital still recorded more than 70 injuries serious enough to report to the federal Occupational Safety and Health Administration.

• Patients can go weeks without seeing a psychiatrist. Legislative Auditor James Nobles, in a scathing report this year, called the hospital “critically understaffed” and suggested inadequate care may violate patients’ constitutional rights.

One result is that basic patient care and case management continue to fall short, according to records and interviews with people with firsthand knowledge.

In an incident last January, for example, a patient suffering a stroke went untreated for four hours while a staff doctor failed to respond to emergency calls from nurses, records show. In the meantime, the nurses did not call 911 or seek help from a clinic steps away. The nurses were cited for neglect and reported to the state Board of Nursing; two doctors directly involved escaped disciplinary action.

In another episode, DHS licensing investigators concluded this month that Christensen committed maltreatment during an incident last April by threatening an uncooperative patient with the use of electroshock therapy. Their finding was changed to “inconclusive” by DHS Inspector General Jerry Kerber, who said that, after much consideration, he didn’t find sufficient evidence to conclude that Christensen’s remarks caused enough emotional distress to harm the patient. Christensen denied to investigators that he ever made such a threat.

Still, investigators’ notes show that, as the incident unfolded, a staff psychologist recounted hearing Christensen tell the patient, “You should be afraid of me. I am the one who is going to shock your brain with electricity.” The patient was described as being “shocked and upset,” according to agency records.

The episode so angered the state ombudsman for mental health and developmental disabilities that this month she filed a formal request to have Human Services Commissioner Lucinda Jesson reconsider the finding.

“I’m gravely disturbed, because there is a huge power differential between the doctor and the patient as shown in that threat,” ombudsman Roberta Opheim said. “Just because you’re short-staffed does not allow you to [ignore] the law when it comes to respecting patient rights.”

In an interview, Kerber acknowledged Christensen’s remark “was certainly a very blunt message’’ and said he has ordered the case referred to the state Board of Medical Practice.

Paperwork lapses

In addition, internal records show that performing the most basic patient-care tasks has often been difficult.

In the past four months, the hospital discharged a patient to a Minneapolis room and board facility where he assaulted a vulnerable female, placed a former patient — a mentally ill sex offender — at the Anoka Regional Treatment Center alongside mentally ill and developmentally disabled women, and left a mentally ill patient at the wrong homeless shelter in Minneapolis without proper “after-care’’ planning. That patient, Raymond Traylor, also was allegedly threatened by Christensen.

About the series About THE series BREAKDOWN, concluding today, examines failures in Minnesota’s mental health system that have left hundreds of psychiatric patients in limbo. Read past segments at startribune.com/breakdown: Sept. 8: Scores of inmates with dangerous psychiatric problems languish in county jails across the state, posing a risk to themselves and others. Oct. 26: The rural mental-health safety net is in tatters, leaving hundreds of patients to wind up in hospital emergency rooms and county jails. Nov. 23: More than 60 inmates have committed suicide in county jails and state prisons, many of them with disorders that were treatable.

As a result of these and similar breakdowns, judges and attorneys in the state’s mental health courts say they sometimes lack information to accurately assess a patient’s public safety risk.

Service, the former medical director, got a firsthand look at record-keeping lapses when she was hired last year as a contractor to monitor patient files because clinicians were too overwhelmed to complete paperwork. Over an 18-month period through last October, she said, the hospital mailed her as many as 10 patient records a week unsecured on her Edina doorstep. Often, she said, she found them inaccurate and illegible.

“You don’t just ship records off to someone’s house. There was no appreciation of the importance of how to formally assess risk,” Service said. “A lot of them were handwritten notes with mistakes, lists of medications administered that didn’t match other records.”

She said the hospital stopped the practice two months ago, after a DHS administrator in St. Paul learned what the clinicians had been doing.

In an interview, Deputy Commissioner Barry said her agency would have addressed Service’s concerns if she had raised them earlier. “There are clearly more appropriate ways to send records,” Barry said. “We can’t fix problems we don’t know about.”

‘Swelled up and purple’

Confusion reigned in the hallways.

Bill Turnbull, who had received electroshock therapy most of his adult life and was undergoing the procedure once a week, screamed that he wanted to die. Every few minutes he took another run that ended with a sickening thud.

Between 5 p.m. and 10 p.m. that August night, his nurses called the supervising nurse practitioner four times, records show. Each time, she refused to issue a restraint order, even though policy allowed it in an ongoing crisis. In so many words, she said Turnbull could keep banging into the wall as long as he didn’t attack anyone else, reports show.

By dawn, Turnbull’s head was “swelled up and purple,” according to reports, with blood leaking inside his skull. The nurse practitioner later told state investigators when she saw Turnbull the next day, she “did not realize it was that bad” and that she should have ordered the restraints. A staffer told investigators, “With all these new rules, we were under the impression that we are not allowed to go hands on …”

Two nurses were blamed for maltreatment and reported to the state Nursing Board; they have hired an attorney. Their supervisor received a day’s suspension. The hospital was found responsible for maltreatment and fined $1,000 by Jesson.

After reviewing the cases of Turnbull and the patient who suffered a stroke, Jesson ordered the hospital’s “conditional” license status — a sort of probation — be extended through 2014. Barry e-mailed the staff to urge everyone to stay committed.

“We need to remember that we have undertaken a huge change in culture and practice,” Barry wrote. “That doesn’t happen overnight, or in a year.”









