{"Short_Answer__76":"201906129","Date__77":"09\/16\/2019","Multiple_Choice__78":"Scott Schifsky","Multiple_Choice__79":"Aric Gregg","Short_Answer__80":"Opportunity Partners - Keith's Place","Short_Answer__81":"Jay McKibbins","Short_Answer__82":"jmckibbins@opportunities.org","Multiple_Choice__84":"Elopement","Multiple_Choice__85":"Hennepin County","Date__86":"08\/24\/2019","Free_Text__87":"VA, Housemate and AP were at food court in Eden Prairie mall. VA needed to go to the bathroom. Bathroom was at sight so AP let VA walk\r\nto the bathroom by himself. AP observed VA walk in to the bathroom but did not observe VA come out. After about 10 minutes, AP went to\r\ncheck the bathroom with Housemate but VA was not there. AP talked to an unknown cleaning lady about contacting the security. AP\r\ncontacted security and also called Nurse and Reporter. Nurse contacted Coordinator.","Multiple_Choice__96":"1","Short_Answer__91":"Staff did not continuously monitor a public restroom door a person with dementia was using.","True_or_False__94":"Yes","Date__97":"10\/13\/2020","Free_Text__98":"Staff drove two housemates to the Eden Prairie mall. The staff and housemates frequent the mall and are very familiar with the area. They parked in the back of the mall parking lot as they prefer the walk into the mall for some exercise. After shopping in the mall they stopped at the food court for lunch. The person who went missing brought his own lunch and after eating needed to use the restroom. This person had never used the restroom at this mall before. Staff stayed with the other person while he walked to the restroom. The restroom sign was in line of sight for the staff and staff saw the person enter the hallway that led to the restroom. There was only one entrance to the restroom area.  \r\n\r\nWhile the person was using the restroom, the staff reported the other person was experiencing anxiety. Staff is trained in positive behavior approaches and did help the person by talking to them while they used a paper bag to take some deep breaths. After about 10 minutes, staff and the person she was supporting went to the restroom area to check on the person as they did not see him exit. While she was assisting the person, she did have line of sight on the exit to her best knowledge. Staff checked the family and womens restroom, while the other person checked the mens restroom. The person was not present. Staff then spoke with a cleaning attendant and she helped contact the mall security.   \r\n\r\nMall security searched for the person while the staff and other person searched around the food court. Mall security then asked the staff to remain at the food court and that they would contact the police to assist.  Staff then called the Opportunity Partners nurse as the typical program manager was on vacation.  \r\n\r\nAt about 12:45 the mall security found the person standing by the staff\u2019s vehicle. Mall security then reunited the staff with the person.","Free_Text__100":"Staff did not continuously monitor a public restroom door a person with dementia was using. This was influenced by staff\u2019s attention being diverted by both the crowded mall, as it was a busy Saturday at the food court, and assisting another person who was experiencing anxiety. The staff and the two people routinely went to this mall and the one person did not return from the restroom as anticipated.  Staff was within line of sight of the the entrance to the bathroom that only had one exit. The staff did not think using the restroom was a risk and assumed he\u2019d return safely given they frequent the mall and are familiar. Staff knew there was not a back door behind the restrooms. \r\n\r\nThe person had only recently been diagnosed with dementia. While the company nurse trained the staff on supporting people with dementia, the staff was not certain what that meant for the person, but did have familiarity with supporting the person. The person also had been grieving the loss  of a long-time friend\/room mate. Person-Centered practices influenced the decision to adhere to the person\u2019s routine and community inclusion activities to have lunch at the mall. This situation was further complicated as the definition of the need of support was not synonimous with the agency\u2019s definition. While the person\u2019s CSSP required 24\/7 supervision, it did not require \u201cdirect line of sight\u201d supervision in the community. Agencies are given flexibility in determining what level of supervision is required when the CSSP is not specific. Both the provider and case manager noted that \u201cdirect line of sight\u201d supervision would require 1:1 staffing, which was not supported in the person\u2019s CSSP or 6790 rate form. \r\n\r\n\r\nThe providers policies allowed for a 1:2 staffing ratio which is influenced by the county via the 6790 rates form and DHS\u2019s DWRS system. The person\u2019s MNCHOICES assessment was not up for renewal for several months which creates more complexity while the person\u2019s dementia as the condition possibly changes or is not understood over time and new symptoms develop. The provider noted that while many times a person with dementia has a higher staffing level in the community, this person did not yet have a higher staffing level as the person\u2019s dementia had just recently developed. The provider had not sought out additional staff or funding for the person yet because they weren\u2019t sure they could add more staff due to the workforce shortage and that the person had not yet had an episode of elopement. The provider noted that staffing levels were typically reactive after incidents rather than proactive to prevent them.","Multiple_Choice__101":"2","Free_Text__102":"This was influenced by staff\u2019s attention being diverted by both the crowded mall, as it was a busy Saturday at the food court, and assisting another person who was experiencing anxiety.","Multiple_Choice__103":"1","Multiple_Choice__105":"0","Multiple_Choice__107":"0","Multiple_Choice__109":"0","Multiple_Choice__111":"1","Multiple_Choice__113":"1","Multiple_Choice__115":"2","Free_Text__116":"This situation was further complicated as the definition of the need of support was not synonymous with the agency\u2019s definition. While the person\u2019s CSSP required 24\/7 supervision, it did not require \u201cdirect line of sight\u201d supervision in the community. Agencies are given flexibility in determining what level of supervision is required when the CSSP is not specific. Both the provider and case manager noted that \u201cdirect line of sight\u201d supervision would require 1:1 staffing, which was not supported in the person\u2019s CSSP or 6790 rate form.","Multiple_Choice__117":"0","Multiple_Choice__119":"0","Multiple_Choice__121":"0","Multiple_Choice__123":"0","Multiple_Choice__125":"0","Yes_or_No__432":"Yes"}