Minnesota Sex Offender Program found in violation of state requirements

The Moose Lake treatment facility failed to implement a medication control plan, which led to residents selling medication to other residents and engaging in suicidal behavior using medications, the Minnesota Department of Health determined.

Minnesota Sex Offender Program building in Moose Lake
The Minnesota Sex Offender Program building at Moose Lake.
2011 file / Duluth News Tribune
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MOOSE LAKE — The Minnesota Sex Offender Program was found by the Minnesota Department of Health to be in violation of several state requirements, including failing to have a medication control plan; to provide timely and appropriate interventions to address resident self-harm and other medical issues; and to ensure resident access to a private phone, according to a state licensing compliance report.

The lack of a medication control plan led to MSOP residents in Moose Lake selling medication to one another for illegal use and to engage in suicidal behavior using medication, the department of health reported last week.

In an Oct. 19 incident report, staff were told by a resident that another resident was "running a script store" and was allegedly threatening peers about receiving money. A staff member reported observing a client approach that resident and ask him for something, who then handed him "something small" that could not be identified.

Another incident report from January 2021 stated a resident requested to move units because he was getting high every day living with the resident mentioned in the October report. The resident making the complaint alleged that the pills they were taking came from multiple clients in the unit.

The program was required by the state to come up with a medication control plan for how administration, distribution and storage of medications at the facility will be handled. In addition, it must record the medications of each resident and periodically review those medication regimens.


The facility also failed to provide timely and appropriate interventions to address resident medical issues and routinely used chemical irritants for resident restraint and compliance.

A series of incident reports between March and December detailed at least six suicide attempts by a resident who would ingest various substances, including large quantities of pills, glass cleaner and contact lens solution. According to the report, facility staff used pepper spay on the resident five times in that period of time to extract the client from his room and gain his compliance after he made threats to himself and staff. Staff also used chemical irritants to induce vomiting after the resident was observed ingesting pills.

The resident, who had been diagnosed with antisocial personality disorder, fetal-alcohol spectrum disorder and multiple mood-related disorders, including major depressive disorder, was examined in a facility Vulnerable Adult Assessment. The assessment did not mention any of the resident's suicide attempts and concluded that the resident was not a vulnerable adult because the personality and mood disorders did not impair his cognitive awareness.

In an interview with the investigators, the resident said when he self-harms, "It always means pepper spray when they want my clothes off," the report states. The client was required to undress for visual body searches after self-harming attempts.

According to the Centers for Medicare and Medicaid Services State Operations Manual, the use of weapons, including pepper spray and mace, for restraint is not considered a safe or appropriate health care intervention. A Minnesota statute declares that pepper spray may only be used for law enforcement or military purposes, or for reasonable defense of the person or person's property.

However, the MSOP's Use of Force and Restraint Policy detailed that chemical irritants may be used to gain control of a situation when it is the safest way to maintain safety, including if there is a threat to the immediate safety of staff or clients.

Several administrative staff were interviewed by the Minnesota Department of Health about chemical irritant deployment procedures and assessment of residents. They stated that the MSOP team is trained to use the chemicals and to decontaminate after. Clients are only medically assessed after chemical deployment if there are reports of concerns from individual clients, a registered nurse said.

Another MSOP resident reported that staff was "ignoring him and making fun of him" for reporting pain for 12 days after a surgery on his genital region. According to the resident, he had to threaten to overdose on medication before he was seen by a provider in the emergency room, who discovered a problematic stitch placement.


In addition, the Moose Lake MSOP was found to violate residents' rights to communication privacy by not providing a phone from which residents could make private phone calls. Several incident reports included in the state licensing compliance report stated that residents requested or attempted to call abuse prevention lines and the Common Entry Point, which receives reports of maltreatment.

Because staff and other residents could hear communication over the phone, residents reported getting "in trouble" for reporting names, and being refused access to the phone to make reports.

The MSOP was required to submit plans for correction for all violations to the Minnesota Department of Health seven days after receiving the report, which was concluded Feb. 1.

Fewer than 8% of the sex offenders receiving treatment in Moose Lake and St. Peter have had confirmed cases of the coronavirus.

Laura Butterbrodt covers health for the Duluth News Tribune. She has a bachelor of arts in journalism from South Dakota State University and has been working as a reporter in Minnesota and South Dakota since 2014.
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