{"Short_Answer__76":"TG_TBI Residential-SLC-2020-05","Date__77":"05\/28\/2020","Multiple_Choice__78":"Tony Gantenbein","Short_Answer__80":"TBI Residential & Community Services","Short_Answer__81":"Keith Comstock","Short_Answer__82":"k.comstock@tbiduluthmn.com","Short_Answer__83":"218-733-1331","Multiple_Choice__84":"Elopement","Multiple_Choice__85":"St. Louis County","Date__86":"03\/20\/2019","Free_Text__87":"TBI Crisis Float was at the Alder home at 5:45pm on Friday, March 20th talking with Dwayne. Crisis Float and\r\nDwayne were outside during the conversation. Dwayne asked if he was able to get his hair done soon and Crisis Float explained that due\r\nto the pandemic the salon was closed until further notice. Dwayne was disappointed that he could not get his hair done. After the\r\nconversation Dwayne walked inside and Crisis Float left the Alder home. At 6:00pm Khun (staff) went to check on Dwayne and he was not\r\nin his bedroom. Khun checked the inside of the house then walked around the outside of the house and could not locate Dwayne. Khun\r\nthen called the Crisis Float to notify them of the situation. Crisis Float began driving around the area looking for Dwayne. At 7:00pm Crisis\r\nFloat notified the Sheriff and completed an Attempt to Locate for Dwayne. Crisis Float continued to search for Dwayne. At 8:30pm the Crisis\r\nFloat asked that the Attempt to Locate be changed to a Missing Persons report. At 4:00am on Saturday, March 21st the TBI Crisis Float\r\nreceived a call from the Duluth Police Department saying that Dwayne had approached them looking for a ride home. Dwayne reported to\r\nthe police and TBI Crisis Float that he eloped from the Alder house and walked to the Kwik Trip where he was able to catch a bus to\r\ndowntown Duluth. Dwayne reported he walked around downtown for several hours before finding a police officer at CVS Pharmacy in\r\ndowntown Duluth. Dwayne returned home at 5:00am and went to bed.","Multiple_Choice__96":"1","Short_Answer__91":"Float staff waited four hours to contact their supervisor about an elopement","True_or_False__94":"Yes","Date__97":"08\/27\/2020","Free_Text__98":"Person was talking with (Alder House staff) about going downtown Duluth to get a haircut. The salons were closed due to the Governor\u2019s Executive Order about COVID 19. DSP went to cook food for dinner. The DSP was the only staff working, normally two staff. SP was attending to the other residents who were asking questions while the SP was cooking food. The SP knocked on bedroom door and there was no answer. The room was empty. The SP began to search the house for 10-15 minutes and then called the crisis float for direction and next steps. The SP immediately began to write up report, Incident Report Internal Review (IRIR). The Alder House DSP worked alone most of March. Quote: \u201cIf two staff were working this elopement could have been avoided because the other staff could drive person downtown Duluth\u201d.\r\nCrisis float takes over the elopement incident and the decision to call 911. Arrives at home and begins the attempt to locate. Drives and searches streets and downtown Duluth for 4 hours. It is protocol to search for 1-2 hours before contacting a supervisor. The Program manager makes the decision to call 911 and report a missing person. The call 911 was to report a non-emergency and provide a description of the person. The role of the crisis float is to fill in gaps as needed in the residential setting. The Crisis float needs to be available to respond to other crisis. The night of the incident the crisis float was moving from a crisis, de-escalating attention seeking behaviors, and then came to Alder House. Priority goes to situations that require hospitalization. During the attempt to locate the Crisis float communicates with the Alder house DSP with updates as needed, about every 15-20 minutes.","Free_Text__100":"The float staff waiting 4 hours (instead of the policy of 1 hour) to contact their supervisor about an individual eloping, was impacted by the staff not seeing it as an emergency . Staff had ideas of where the person would go and that they\u2019d be able to find them. The float staff\u2019s ideas were impacted by their familiarity with the person, they knew their favorite places to go, that they had no previous elopements, and the person mentioned wanting to get a haircut. The staff feeling like they could find the person was also influenced by the empty streets in Duluth due to the Governor\u2019s Stay at Home order. The Governor\u2019s Stay At Home Order was issued due to COVID-19 in an attempt to slow the curve of the virus spreading. The Order required people to stay in their home unless they were conducting essential business. This influenced the streets of Duluth to be empty, businesses to be closed and the staff feeling as though the person should have been easier to spot. Other contributing factors to not seeing this elopement as an emergency and waiting to call the supervisor was that the staff maintained constant communication with the house staff about search strategies and updates and they knew the person had the ability to navigate the community independently .  \r\nAdditional influences to waiting 4 hours to call the supervisor may have been the staff\u2019s desire to avoid the 245D\/Positive Support Rule reporting requirements because the process can be very time consuming . Additionally, staff waited to call the supervisor because it is provider practice is not to contact supervisors if the elopement is supervised or the person\u2019s whereabouts are known and they were confident they would be able to find the person .  St. Louis County had a recent history of attempting to decrease 911 calls, and had brought together HCBS providers, Law Enforcement Officers, County staff and Healthcare staff to work on this issue and created a Person Centered Incident Matrix to help provider\u2019s parse out when 911 should be called and how to avoid overusing the 911 relay. The staff noted they were aware of the Person-Centered Matrix and this influenced the staff to exhaust all known places the person might go before contacting the supervisor about the elopement .","Multiple_Choice__101":"3","Free_Text__102":"The float staff waiting 4 hours (instead of the policy of 1 hour) to contact their supervisor about an individual eloping, was impacted by the staff not seeing it as an emergency.\r\n\r\nOther contributing factors to not seeing this elopement as an emergency and waiting to call the supervisor was that the staff maintained constant communication with the house staff about search strategies and updates and they knew the person had the ability to navigate the community independently . \r\n\r\n  St. Louis County had a recent history of attempting to decrease 911 calls, and had brought together HCBS providers, Law Enforcement Officers, County staff and Healthcare staff to work on this issue and created a Person Centered Incident Matrix to help provider\u2019s parse out when 911 should be called and how to avoid overusing the 911 relay. The staff noted they were aware of the Person-Centered Matrix and this influenced the staff to exhaust all known places the person might go before contacting the supervisor about the elopement .","Multiple_Choice__103":"0","Multiple_Choice__105":"0","Multiple_Choice__107":"0","Multiple_Choice__109":"0","Multiple_Choice__111":"1","Multiple_Choice__113":"0","Multiple_Choice__115":"2","Free_Text__116":"Other contributing factors to not seeing this elopement as an emergency and waiting to call the supervisor was that the staff maintained constant communication with the house staff about search strategies and updates and they knew the person had the ability to navigate the community independently .","Multiple_Choice__117":"1","Multiple_Choice__119":"0","Multiple_Choice__121":"0","Multiple_Choice__123":"1","Multiple_Choice__125":"0","Yes_or_No__432":"Yes"}