{"Short_Answer__76":"201904881","Date__77":"08\/15\/2019","Multiple_Choice__78":"Marilee Bengtson","Multiple_Choice__79":"Tim Sullivan","Short_Answer__80":"Accessible Spaces - Silver Lake","Short_Answer__81":"Stephen Vander Schaaf","Short_Answer__82":"svanderschaaf@accessiblespace.org","Short_Answer__83":"6516457271","Multiple_Choice__84":"Elopement","Multiple_Choice__85":"Hennepin County","Date__86":"04\/07\/2019","Free_Text__87":"Reporter heard from staff at VA's group home today that VA left sometime between mid day on 7\/3\/2019 and early morning 7\/4\/2019. VA\r\ntold one staff member on 7\/3\/2019, \"I'm moving out.\" and when the staff asked where VA told him \"I'm not going to tell you.\" and VA was\r\nnoticed gone early in the morning of 7\/4\/2019. VA's Case manager has received a voice message from VA saying that she is ok and\r\neverything is fine but has not spoken with VA yet. Reporter has tried contacting VA but after ringing a few times VA's phone goes to voice\r\nmail and VA's voice mail is currently full.","Multiple_Choice__96":"1","Short_Answer__91":"Staff did not report Individual's absence for 5 days.","True_or_False__94":"Yes","Free_Text__98":"Incident report description\r\nIncident date:\t07\/04\/2019\r\nIt was reported to CEP, that the individual left her group home, which was noted the early morning of 7-4-19, and has not returned for 5 days.  The reporter of the incident had been told by group home staff that the individual had told staff \u201cI\u2019m moving out\u201d.   When staff asked where, the individual stated, \u201cI\u2019m not going to tell you\u201d.  The individual\u2019s case manager reportedly tried calling the individual, but her phone goes to voicemail and message states it is full.\r\n\r\nDebriefing information for Learning Point \r\nDebriefing date: November 18, 2019\r\nPerson debriefed: Home Supervisor\r\nIndividual is her own guardian and has an ongoing medical condition which requires her to attend numerous and frequent medical appointments and at times hospitalizations.  There is only one staff on site at the 4-person group home at a time.  This individual makes and attends her medical appointments by herself and is allowed to be in the community unsupervised.  \r\n\r\nDuring the time of the incident, the home supervisor was on vacation.  Several days prior to the incident, the individual reported to staff that she was moving out of the group home.  The individual reportedly stated she was not going to tell staff where.  One staff emailed the home supervisor (who was on vacation) a day after the incident asking the supervisor if she was aware the individual was moving out of the group home.  \r\n\r\nThe morning of the incident, the individual reported to early morning staff she was moving and would not say where to.  At the time she left the group home, she told a different staff she was going to the hospital.  The individual had unspecified alone time in the community, so staff did not follow her. It was typical for her to leave to do what she wanted without telling staff where she was going. Staff also believed the individual was going to the hospital and did not follow elopement protocol. \r\n\r\nThe individual did not come back to the group home the evening she left.  Staff did not follow up with trying to call the individual, or the covering supervisor, case manager of individual or 911.  Staff believed the individual had either moved out of the home or was hospitalized and due to individual being her own guardian, did not consider this an elopement.   \r\n\r\nWhen the supervisor returned from vacation, she followed up by calling case manager, individual, and reporting the incident.  The individual did go to the hospital and was hospitalized inpatient.  She returned to the group home.","Free_Text__100":"Narrative\r\nElopement\r\nDecember 12, 2019 Mapping\r\n\r\n\r\nLearning Point:  Staff did not report individual\u2019s absence for 5 days.\r\n\r\nStaff not following-up about where the individual was for 5 days after she left the group home was influenced by the staff believing the notification policy wasn' t applicable TO this individual AND situation.Several factors influenced staff believing the policy wasn 't applicable including the staff and the individual being newer to the home and the individual being her own guardian.  The two newer staff were less familiar with the support needs of this individual.  As her own guardian, the individual made her own healthcare decisions and did not have to share the information with staff. The individual had a history of being admitted to a hospital without staff knowledge.  The individual had a history of hospitalizations lasting several days which further contributed to staff not believing the policy was applicable.  The provider did have a policy that emergency contacts should be notified if an individual who is their own guardian is hospitalized which was not followed because staff did not know the individual went to the hospital. \r\nOther contributing factors to staff believing the notification policy wasn't applicable was the individual was her own guardian and allowed to be in the community unsupervised for an indeterminate amount of time.  The individual\u2019s Community Support Plan (CSP) and Community Support Service Plan (CSSP), which is completed by the individual and a county case manager, did not indicate how much time the individual could have.  Staff would have to follow the consented to CSP and CSSP.  Case Manager\u2019s comply with 245D for how and what is written in an individual\u2019s CSP and CSSP.  The individual approved what was included in the plans.  The individual having unspecified time in the community influenced staff's decision that documenting when the individual left was sufficient. The individual regularly was in the community unsupervised so staff felt like it was okay to not notify anyone beyond the logging of their activity in the individual\u2019s logbook. It was noted that staff didn\u2019t have much time to communicate between shifts, so communication often took place in the logbooks instead of staff communication directly with one another regarding the individual.  The individual was admitted to this home directly from a discharge from a hospital and this home was one of only two choices.\r\n\r\nAnother influencing factor affecting staff not following-up to individual\u2019s whereabouts was the staff being worried about calling their supervisor or manager when it wasn't necessary due to being of a culture that deffers to authority figures.   Staff were not of the dominant culture and may have felt intimidated by calling a supervisor with questions.\r\n\r\n\r\nAdditionally, staff not following up on the individual was influenced by the house supervisor being on vacation.  At the time, the provider was short staffed and some of the shifts at this residence were covered by non-routine or fill-in staff.  A lack of cross-training on the individuals supports needs and plan of care could influence staff not reporting the individual\u2019s whereabouts.  The provider's overall staff shortage, and not just this residence, contributed to having non-routine staff supporting individuals and not having enough time to train non-routine staff on all the support needs of individuals in the group home.  Staff shortage is influenced by the state and national wide direct support professional workforce shortage. \r\n\r\nStaff not following up on their individual\u2019s whereabouts was influenced by the individual keeping an irregular schedule and would often not tell staff where she was going or would tell different information to different staff about where she was going or would be. The individual was described as having much different support needs than the three other individuals living in the group home.  The decision to place the individual in a four person home was impacted by an overall lack of community residential settings in Minnesota.","Multiple_Choice__101":"1","Multiple_Choice__103":"2","Free_Text__104":"The individual was admitted to this home directly from a discharge from a hospital and this home was one of only two choices. The individual was admitted to this home directly from a discharge from a hospital and this home was one of only two choices.\r\n\r\nThe individual was described as having much different support needs than the three other individuals living in the group home.  The decision to place the individual in a home was impacted by an overall lack of community residential settings in Minnesota.  \r\n\r\nThe two newer staff were less familiar with the support needs of this individual.\r\n\r\nAt the time, the provider was short staffed and some of the shifts at this residence were covered by non-routine or fill-in staff.  A lack of cross-training on the individuals supports needs and plan of care could influence staff not reporting the individual\u2019s whereabouts.  The provider's overall staff shortage, and not just this residence, contributed to having non-routine staff supporting individuals and not having enough time to train non-routine staff on all the support needs of individuals in the group home.","Multiple_Choice__105":"2","Free_Text__106":"The individual\u2019s Community Support Plan (CSP) and Community Support Service Plan (CSSP), which is completed by the individual and a county case manager, did not indicate how much time the individual could have.  Staff would have to follow the consented to CSP and CSSP.  Case Manager\u2019s comply with 245D for how and what is written in an individual\u2019s CSP and CSSP.","Multiple_Choice__111":"3","Free_Text__112":"Staff not following-up about where the individual was for 5 days after she left the group home was influenced by the staff believing the notification policy wasn't applicable to this individual and situation. Several factors influenced staff believing the policy wasn't applicable including the staff and the individual being newer to the home and the individual being her own guardian.  \r\n\r\nThe individual having unspecified time in the community influenced staff's decision that documenting when the individual left was sufficient. The individual regularly was in the community unsupervised so staff felt like it was okay to not notify anyone beyond the logging of their activity in the individual\u2019s logbook. \r\n\r\n As her own guardian, the individual made her own healthcare decisions and did not have to share the information with staff. The individual had a history of being admitted to a hospital without staff knowledge.  The individual had a history of hospitalizations lasting several days which further contributed to staff not believing the policy was applicable.","Multiple_Choice__119":"2","Free_Text__120":"The individual was described as having much different support needs than the three other individuals living in the group home.  The decision to place the individual in a four person home was impacted by an overall lack of community residential settings in Minnesota.","Yes_or_No__432":"Yes"}