The suicide of a mentally ill, chemically dependent patient at a state facility in St. Peter on Sunday night will be investigated by an independent examiner amid allegations by employees and union officials that short-staffing contributed to the death, state officials said Thursday.
Union, employees say staffing shortage contributed to suicide at state facility
Staffing shortage had role in tragedy, union charges.
March 13, 2015 at 4:47PM
Logan Brodal, 28, who had been committed by a judge to the Community Addiction Recovery Enterprise (CARE) program, was found unconscious in the facility's exercise room and could not be resuscitated.
Officials of two unions representing the facility's employees say they warned state officials months ago that short-staffing could lead to a tragedy, which was confirmed in e-mails obtained by the Star Tribune.
The death comes as the Minnesota Department of Human Services (DHS), which operates the CARE program, is moving to eliminate a budget shortfall by cutting a variety of treatment programs, including the CARE facility in St. Peter.
"On more than one occasion, we said, 'This has to be dealt with or someone will kill himself,' " said Richard Kolodziejski, a spokesman for the Minnesota Association of Professional Employees (MAPE).
Deputy Human Services Commissioner Anne Barry said Thursday she has ordered an outside review of the incident "because so many questions are being raised" over the death.
"A family has lost a loved one, we owe it to the family," Barry said. "This is one case where we knew there were questions and a lot of outside attention, so we said, 'Let's turn it over' to an outside examiner."
Suicide attempts number roughly 30 to 40 a year in state-operated care facilities, but Brodal's is the first successful attempt in the past four years, according to state records.
Accounts of Brodal's death by sources familiar with the incident depict a chaotic series of breakdowns and a staff members so overwhelmed that they had to enlist the help of other patients as they attended to the crisis. At the time, three nurses were on duty to care for about 18 patients, according to people with knowledge of the events.
When Brodal was found by a nurse hanging in the facility's exercise room after 9 p.m., other patients helped hold up his body while a staff member loosened the bedsheet around his neck, the sources said, and one even helped in the effort to resuscitate him.
Staff also gave patients a key to a secured door so they could admit an ambulance crew while a staffer stayed at Brodal's side. In addition, they said resuscitation efforts were hampered because the facility's emergency oxygen container was kept in a locked patient exam room. The facility lacked a specialized cutting tool commonly kept at such facilities to quickly sever ropes or sheets in suicide attempts, one source said.
About a week ago Brodal was taken off a suicide watch where he was supposed to be monitored every 15 to 20 minutes. The St. Peter facility has surveillance cameras in central areas, but a source said monitor screens go unobserved for long periods because the staff members are busy caring for patients, who suffer from a range of conditions, including mental illness, chemical dependency and dementia.
On the night of Brodal's death, nobody was assigned to watch the monitors, the source said. Jennifer Mundt, spokeswoman for the American Federation of State County and Municipal Employees (AFSCME) local in St. Peter, said Thursday that staff have been told that monitoring the cameras is not part of their duties.
In a January memo, Barry said that the rates paid for DHS chemical dependency treatment failed to cover the costs of serving the complex needs of patients at the CARE program statewide, and that 174 beds will be cut to 70 by June 2016.
Last month, in a string of e-mails with union officials, she acknowledged that budget pressures have affected staffing.
"We are also trying to balance against the serious deficits we are running in our programs," she wrote. "We will do everything we can … so we don't force staff to work unreasonable amounts of overtime and make difficult jobs even more difficult."
But the e-mails show union officials warned that "skeleton crew" operations were causing burnout. "Folks are getting exhausted with the hours they are forced to work," a union official replied.
"When you have to have a patient letting an ambulance crew into the building, then you have a problem," Chuck Carlson, vice president of the AFSCME local, said.
'How did this happen?'
In an interview this week, Brodal's father said he thought his son, a Brainerd native who had bipolar disorder, was finally in good hands.
In the past year, Bryan Brodal said, his son tried to kill himself twice by drug overdoses and a judge ordered him committed to state care. He made his way through various state facilities in Baxter, Fergus Falls, and finally St. Peter.
"I was at peace," Brodal said. "I thought, 'Well, finally, he's court-ordered and couldn't leave on his own.' I thought I'd get my son back."
"My question is," he added, "how did this happen in a supposedly safe, secure facility?"
Brodal will be buried Saturday at Lake Edward Cemetery in Crow Wing County.
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In a story published Apr. 12, 2024, about an anesthesiologist charged with tampering with bags of intravenous fluids and causing cardiac emergencies, The Associated Press erroneously spelled the first surname of defendant Raynaldo Rivera Ortiz. It is Rivera, not Riviera.