MINNEAPOLIS (WCCO) -- A report released by the Centers for Medicare & Medicaid Services says St. Cloud Hospital failed to give direct psychiatric care to a patient who shot and killed a deputy last month.
On Sunday, Oct. 18, Aitkin County Deputy Steven Sandberg, 60, was overtaken by Aitkin County resident Danny Leroy Hammond, 50, who was receiving medical care following an earlier domestic dispute.
Investigators say Hammond was not restrained to his bed and somehow managed to wrestle the deputy's service weapon away from Sandberg and shoot him, killing him.
Hammond was immediately Tasered and apprehended, but died soon after likely suffering from cardiac arrest.
On Monday, the federal health agency released the report on the incident, saying Hammond consistently talked about killing himself after arriving at the hospital, and had previously tried to commit suicide.
"As a result, the patient was placed on an involuntary 72-hour hold by a Physician Assistant," the report said. "The patient was considered violent and dangerous. The patient had a criminal history."
The hospital staff requested help from law enforcement to guard the patient after he left ICU. The report also says hospital workers witnessed Hammond hallucinating, which was reported but no actions were taken.
However, despite remaining suicidal and potentially violent, the Physician's Assistant determined that Hammond did not need any psychiatric intervention. Thus, Hammond was never evaluated by a psychiatrist at any time and was placed on a medical unit in the general population.
Because of this, the "medical staff failed to ensure that the patient's care and treatment plan was organized to include services by medical specialty, in accordance with the patient's psychiatric needs and acute system", the report said.
Less than three days after the psychiatric hold, Hammond managed to get the gun from the deputy and kill him.
In response, the agency placed the hospital on "immediate jeopardy" status last month, meaning the hospital was put on notice for violating federal standards and could lose federal funding until it corrected its policies.
The changes include training for staff reinforcing policy that 72-hour holds can be ordered only by physicians -- not physician assistants, and that psychiatric consultations and treatment must continue until the hold is lifted. Furthermore, the attending physician and psychiatric provider must agree that services or treatment are no longer necessary.
The hospital says it has since implemented a plan of correction. The immediate jeopardy status was removed on Oct. 28, 2015.
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