Anoka state mental hospital violated basic rules for patient care, feds say

The state's second-largest mental hospital put vulnerable patients in danger by violating basic procedures designed to ensure individualized treatment and safe medical care, according to a federal review.

As a result, Anoka-Metro Regional Treatment Center put its crucial federal funding at risk.

The 175-bed hospital, which treats many of the state's most challenging psychiatric patients, used generic treatment plans that failed to recognize the complex conditions and unique therapeutic needs of some patients, investigators found.

Psychiatrists familiar with the findings say the repeat violations raise serious questions about the quality of treatment at a facility that has struggled to bring violence under control amid a swelling population of mentally ill patients it receives from jails.

In one case, a patient who had attempted suicide 40 to 50 times since age 11 was admitted to Anoka-Metro with symptoms of psychosis. While at the hospital, the patient cut his forearm with broken glass and tied a shoelace around his neck, yet his treatment plan failed to address suicidal ideation as a risk. Another patient was given a potent antipsychotic drug, Haldol, even after a judge had ordered that the drug not be administered to the patient.

These lapses lie at the heart of a recent review which led the U.S. Centers for Medicare and Medicaid Services (CMS) to warn that the facility could lose its federal funding. Though unlikely, the termination of federal funds — about $3.5 million annually — would cripple an institution that has long been a critical piece of the state's social safety net for adults with serious mental illness.

"This is absolutely appalling," said Sue Abderholden, executive director of the Minnesota chapter of the National Alliance on Mental Illness (NAMI). "This is supposed to be the pre-eminent facility in the state to send people with serious mental illnesses, and they can't even get their patient treatment plans right."

In an interview last week, state Human Services Commissioner Emily Johnson Piper, whose agency oversees the hospital, referred to the unauthorized use of an antipsychotic drug as "absolutely unacceptable," and said the state is taking immediate steps to bring the hospital up to federal standards. This includes the creation of a team of "treatment planning mentors" to audit treatment plans, increased training and contracting outside experts, among other steps.

Training staff to write more individualized treatment plans "is one of the floor standards of retaining funding from the federal government," Piper said. "That alone is telling me this is important and is something we need to do right."

The patient-care lapses present fresh concerns for a hospital already hobbled by a surge in patient assaults and an exodus of professional staff. Legislation passed in 2013 requires state facilities like Anoka-Metro to find beds within 48 hours for patients committed by a judge as mentally ill. The so-called "48-hour rule" has led to an influx of sometimes violent patients at Anoka-Metro, and state officials and some lawmakers have blamed the rule for many of the hospital's safety problems.

But the CMS review worries mental health advocates because it points to a more serious concern: basic patient care. Doctors, nurses and social workers rely on treatment plans to identify a patient's nuances and triggers for harmful behavior. Incomplete or non-individualized plans can prevent patients from progressing in therapy and can prolong costly hospitalizations.

Psychiatrists said the poor plans may partly explain why Anoka-Metro has struggled in recent years to discharge patients sooner. Nearly half of the 101 patients currently there no longer meet the hospital-level criteria for care but are kept at the hospital because they have nowhere to go in the community. In 2013 alone, patients spent a total of 13,800 unnecessary days at Anoka-Metro after they were treated — enough to care for another 140 patients, according to a state legislative report.

Lloyd Wells, president of the Minnesota Psychiatric Society, said the deficiencies cited by CMS are "the most egregious" he has seen in his 42-year career. "Surely we can do better as a state for the hospital caring for the very sickest psychiatric patients," he said.

A CMS inspection in October found multiple cases in which treatment plans at Anoka-Metro failed to address the severity of patient illnesses, as well as warning signs of aggressive or self-injurious behavior. The plans sometimes contained "generic interventions" that were "normal functions of a professional discipline" involved in the patient's care, according to the CMS review.

As an example, a woman was admitted to Anoka-Metro in August with bipolar disorder and fluctuated between "elevated mood and suicidality," records show. Yet her treatment plans did not propose any actions related to her suicidal tendencies or any of her specific diagnoses, which included substance abuse, traumatic brain injury and post-traumatic stress disorder.

CMS also found at least two cases in which hospital staff took measures that were not authorized. In one, an agitated patient was prescribed Haldol, an antipsychotic drug, after she emerged from her room "entirely naked," and was screaming and threatening violence. The patient was then given the medication on at least six occasions. Yet, in reviewing the patient records, CMS reviewers found a judge's notice stating that Haldol "shall not be administered" to the patient. The hospital has launched an investigation to review the psychiatrist who ordered the excluded medication, records show.

In another case, CMS found a patient was intermittently placed in a wheelchair restraint, to prevent the patient from falling, without being evaluated for the restraint and without proper documentation — a violation of rules designed to prevent unnecessary restraints.

Dave Hartford, who was administrator at Anoka-Metro from 2004 to 2011 and now oversees behavioral services for CentraCare Health, a private hospital-clinic system, said the findings are "alarming" and suggest the hospital may be understaffed and overwhelmed by an influx of aggressive patients from jails. Even so, he said there is "no excuse" for not having individualized treatment plans. "No matter how you slice it," he said, "that is just the basic standard of care."

To retain federal funding, the Department of Human Services is collaborating with CMS on a plan to improve conditions at Anoka-Metro. The state expects to complete that plan by March 5.

Chris Serres • 612-673-4308

Twitter: @chrisserres