The Minnesota Security Hospital is being fined $1,000 and the conditional status of its license is being extended through late 2016 after investigators found the facility failed to provide necessary care and supervision to two mentally ill patients — and one of those men ultimately killed the other, officials announced Tuesday.

Darnell Dee Whitefeather, 32, is charged with murder for allegedly stomping on the head of 41-year-old Michael Francis Douglas as many as 30 times on Jan. 22 because he was angry at staff and wanted to get their attention, according to a criminal complaint.

In an investigative report released Tuesday, the Department of Human Services called it an “unacceptable failure” and said: “No corrective action can adequately address the tragedy.”

DHS said one security counselor didn’t do hourly rounds on the night of the attack, and was responsible for neglect. The investigation also concluded the facility failed to provide staff with tools, training and strategies to reduce aggressive incidents.

The security counselor was told another act of maltreatment would disqualify him or her from providing care.

Human Services Commissioner Lucinda Jesson said the problems can’t be traced to one person. An order extending the facility’s conditional license calls for more training hospital-wide on a new, patient-focused approach.

The Minnesota Security Hospital has had a series of management lapses in recent years. Jesson placed it on conditional license status in 2011 based on two findings of maltreatment. Since then, there have been three more such findings, the report said. Gov. Mark Dayton said the hospital was in “crisis” after he visited in 2012.

The DHS documents released Tuesday said some problems stem from the building’s physical design. Lawmakers approved more than $56 million for improvements to make the units safer.

In addition, the hospital had historically been over-using seclusion and restraints to manage patient behavior. But as the hospital shifted away from that in recent years, the investigation found, staffers weren’t properly trained and were not engaging with patients enough. DHS has outlined training protocols, one-on-one coaching, and a mentoring system to educate all hospital staff on tools they can use to keep problems from getting out of hand.

“I think that the majority of our employees at security hospital are incredibly well-intentioned, working incredibly hard, and very committed to the new way of doing things,” Jesson said.

The January attack occurred on Unit 800, where patients in crisis are mixed with new admissions. On the night of the attack, there were 14 patients in the unit and seven staff members — including five security counselors.

The investigation found some staffers were unfamiliar with recent histories of Whitefeather and Douglas — Whitefeather had recently assaulted a patient in another unit and was having issues with his medication — and unfamiliar with their treatment needs. Other patients knew Whitefeather had hit Douglas in the head earlier in the evening, and that he had talked about assaulting someone in order to get staff to listen to him.

One patient saw Whitefeather go into Douglas’s room after dinner that night, the investigation found. That patient heard fighting, and saw Whitefeather emerge “bloody,” but didn’t tell anyone. Patients said they knew something happened, and they waited for rounds.

“Yet despite seven staff on duty serving 14 patients, it was likely that 1 1/2 hours passed before staff were aware that a patient was lying on the floor, dying, in this locked living unit,” the report said.