High-needs boy ends up in emergency room amid mounting pressure from Minnesota child welfare system

An embarrassing situation unfolds in the emergency room of Ridgeview Medical Center in Waconia, where a 10-year-old boy with severe autism and aggression has been confined for seven months.

Foster and group homes can’t handle him, so county guardians keep sending him back to the emergency room, the only place legally required to take him. Without schooling or specialized therapy, the boy and the staff are stuck in a cycle of confrontation. Clashes with nurses, support staff and security guards forced some workers to quit and left others bruised and injured.

“This kid, he just created complete chaos in the area,” said one emergency worker who cared for the child, who asked not to be named for fear of losing his job. “We all just feel very helpless, hopeless.”

Ridgeview is an extreme example of a growing problem in Minnesota for hospitals large and even small — boarding children with uncontrolled behavioral and developmental problems. Last spring, M Health Fairview Masonic Children’s Hospital was so overwhelmed with such children that it converted the emergency room into a shelter for them.

Around the same time, a 10-year-old arrived in Waconia hospital emergency room And except for one unsuccessful three-day attempt to transfer him to a group home in the Twin Cities, the boy was placed in a four-room emergency unit designed for mental health patients.

The boy attacked a worker in May, hitting her in the back of the head and causing a concussion, according to a report filed last week with the Carver County Sheriff’s Office. The worker, whose name was redacted from a copy of the report provided to the Star Tribune, suffered lingering effects from the concussion, preventing her from returning to full-time work until September.

ERs are a dumping ground by default because of a federal law — the Emergency Medical Care and Labor Act, or EMTALA — that requires them to screen and stabilize all patients who show up at their doors. The law also requires “appropriate” transfer of patients, but in the case of troubled children, that often means group homes or inpatient treatment centers full of waiting lists. And so they wait.

“For children with autism, children with developmental delays, the worst possible scenario would be to sit in emergency department” said Lew Seidner, director of transition and triage services at M Health Fairview. “They need predictability. They need structure. If they don’t have that predictability, that maturity, they get excited. When they get excited, people around them get excited, and it can lead to physical confrontations.”

Part of the problem is that children with developmental or behavioral problems don’t necessarily meet the criteria for admission to inpatient psychiatric or other units, he said. Mason eventually closed his shelter because it was expanded social workers to contact parents and county child welfare agencies and find placements for them.

But the progress was temporary. Earlier this month, the hospital reported a new wave of baby arrivals. What used to be two to four children a month has now increased to about 15, half of whom are in county custody. Their average length of stay in the emergency room is 12 days, but some have stayed up to six months.

The sheriff’s report is the only public document detailing the problems at Ridgeview’s emergency room. The worker said she wanted to file something because “the medical center is not taking any steps to protect the staff.”

Two sources at the hospital spoke of other incidents. This fall, a nurse suffered a severe nose injury after a child head-butted her during an argument over a pen.

The child, who has not been named in this story, had a traumatic upbringing.

The outburst shortly before his second birthday prompted his mother to remove him from the bathtub at their home and leave his younger brother unsupervised, court records show. The brother and sister drowned, the mother was sentenced to four years in prison, and the older boy was placed in the custody of Sibley County Human Services. The placement from that time with his grandmother and foster families was short-lived.

The hospital hopes to transfer him to a facility anywhere in the US that will be equipped for children with autism and aggressive behavior. But no one has found a place for him yet. Sibley’s child welfare supervisor did not respond to requests for comment.

Privacy protections prevented Ridgeview CEO Mike Phelps from discussing any specific boarding situations at his ED, but he said it’s a growing problem for many hospitals.

Children’s Minnesota is opening an inpatient psychiatric unit in St. Paul next month. However, Phelps said the expansion and recent state investments in mental health are not really addressing this group of children. More specialized inpatient treatment facilities and group homes, as well as more staff, are needed to maximize the capacity that already exists.

“I can appreciate building inpatient psychiatric beds — that’s great — and investing in outpatient mental health services,” he said. “But it’s in between, and it’s a subset of kids who just don’t have a place to go.”

The district reportedly asked Ridgeview to transport the child to the school, but the hospital is not willing to do so. Hospitals receive little or no reimbursement for children admitted to their emergency rooms in these nonclinical situations.

Phelps said he could not confirm the school’s request, but in general, districts are asking hospitals to do more as they become de facto homes for children. He disagreed with the sheriff’s statement that “nothing” was being done and said “the safety of our employees is a priority.”

Ridgeview recently doubled the number of security personnel and provided training in de-escalation tactics and dealing with aggressive behavior, the hospital said in a written statement. In severe cases, individual supervision is used with backup staff nearby. The staff tried to connect with the children in the hostel by bringing clothes and playing games with them.

Seidner said consistency is critical. Staff at the U of Pediatric Hospital are encouraged to use the same approaches when rewarding or disciplining children who end up in the emergency department. The varied approaches create confusion that leads to excitement. Some nurses would reward one child’s good behavior, such as with ice cream, but then the child would become upset when the others didn’t, he said.

“We can’t have a personal style that affects how they interact with patients,” he said. “What we try to do for patients, if possible in these conditions, is to create as much of that consistency as possible to allow them to be as calm as possible.”

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