{"Short_Answer__76":"201906219","Date__77":"09\/16\/2019","Multiple_Choice__78":"Tony Gantenbein","Multiple_Choice__79":"Jill Tilbury","Short_Answer__80":"Dungarvin - Brooklyn Park","Short_Answer__81":"Heather Golden","Short_Answer__82":"hgolden@dungarvin.com","Multiple_Choice__84":"Elopement","Multiple_Choice__85":"Hennepin County","Date__86":"08\/24\/2019","Free_Text__87":"On 8\/24\/2019, VA and AP went to the Minnesota State Fair. An unknown event occurred between 12:30 PM and 5:30 PM wile VA was\r\nunsupervised. VA was unsupervised for approximately thirty minutes.\r\n\r\nReporter found out 8\/26\/2019. VA had appointment with Psychologist at 3:30 PM. Behavior Specialist accompanied VA to appointment. VA\r\ntold Psychologist \"while at the Minnesota State Fair on Saturday, I was alone for about thirty minutes.\" VA said AP walked away from VA. VA\r\ncould not find AP. AP found VA.\r\n\r\nReporter asked AP to explain. AP said VA had a rental scooter while at the Minnesota State Fair. VA told AP she was going to the bathroom\r\non scooter, and took off. AP could not keep up with scooter and soon lost VA. AP continued to search for VA. Approximately thirty minutes\r\nlater AP found VA near a bathroom.\r\n\r\nReporter noted that VA has a previous history of false reporting.","Multiple_Choice__96":"1","Short_Answer__91":"Staff lost sight of a person at the State Fair","True_or_False__94":"Yes","Date__97":"10\/25\/2019","Free_Text__98":"Collaborative Safety \u2013 Systems Mapping \r\nCase Summary\r\nOctober 14, 2019\r\nHennepin County\r\n\r\n\r\nLearning Point #1: Staff lost sight of a person at the State Fair.\r\n\r\nLearning Point #2: Staff brought his son along on this community outing. \r\n\r\nIncident report description\r\n\u2022\tIncident date: 8\/24\/2019, between 12:30 PM and 5:30 PM\r\n\u2022\tReport date: 8\/27\/2019 4:11PM\r\n\r\nStaff and person went to the Minnesota State Fair on a Saturday afternoon. During this outing, the person was unsupervised for approximately thirty minutes. The person had a rental scooter and took off on it to go to use the bathroom. The staff could not keep up with the scooter and lost sight of the person. Approximately 30 minutes later, staff found the person near the bathroom. \r\n\r\nTwo days later, the reporter found out about the incident during an appointment between the person and a Psychologist when the person told the Psychologist \"while at the Minnesota State Fair on Saturday, I was alone for about thirty minutes.\" \r\n\r\nDebriefing information for learning Point #1, October 25, 2019\r\n\r\nStaff participated in a human factors debriefing, led by a Safety Analyst, on October 25, 2019.\r\n\r\nUpon arrival at the State Fair, the person rented an electric mobility scooter for people with disabilities. The staff brought his 10 year old son along to the event. The staff\u2019s attention was influenced by the person\u2019s behavior as they began walking into the Fair, when the person said she wanted to go to the beer garden and drink beer. This action triggered the staff to wonder if this was a good idea. \r\n\r\nShortly after arriving, the staff and his son sat down to eat some food while the person used the scooter to go and browse at a souvenir stand within eyesight. The crowd at the Fair impacted the staff\u2019s focus when he lost sight of the person on the scooter during the outing. Staff reported he was not distracted by his son\u2019s presence. \r\n\r\nDebriefing information for learning Point #2, October 25, 2019\r\n\r\nDuring the debriefing session for Learning Point #1, Staff shared he brought his son along to the outing after the VA told him she thought it was fine. He explained it was a last minute decision because of issues around child care coverage.\r\n\r\nResult of Incident\r\nStaff reported going to the beer garden to search for the person. She was not there, so he called her on her cell phone. She answered his call, but could not tell staff exactly where she was. This phone call went on for about 30 minutes until staff located the person.","Free_Text__100":"The crowd size, unfamiliarity with the State Fair and the person, impacted staff losing sight of the individual. When the staff lost sight of the person, his attention was divided between his 10-year-old son and the person. Staff brought their son along on the outing because the person offered for him to come along. The person likely offered because if staff was unable to work the person would be unable to go to the fair as the person overheard a conversation the staff had about his son not having childcare on the day of the Fair. The provider was experiencing a staff shortage and would not have been able to find another staff to go to the fair with the person. \r\n\r\nAnother contributing factor to losing sight of the person was that staff did not perceive a risk of losing the person because there was no elopement history. Therefore, staff felt comfortable bringing their son. Staff also knew the person\u2019s high level abilities to be independent and capabilities to navigate the scooter, which further supported their decision to have divided attention between the person and their son.  The provider has a policy that allows staff to use judgment\/interpretation of the Coordinated Services & Support Plan (CSSP) as long as staff is attentive to the persons needs without direct line of sight. The provider allows this room for staff judgment because it gives staff the space and ability to support each person as they need and choose. \r\n\r\nThe Case Manager approved the decision not to require a line of sight on the person while out in the community. The person\u2019s history of challenging behaviors influenced the Guardian\u2019s directive to the Case Manager not to include any alone time in the CSSP and the Case Manager's decision to include a 1:1 staffing ratio on public outings in the CSSP. This requirement was an influence on how the provider selected staff for the outing. An industry wide staffing shortage impacted the providers\u2019 ability to hire and retain part-time, intermittent, 1:1 activities staff. The HCBS Rule on Community Inclusion and Person Centered Planning and Person Centered Thinking influenced the Case Manager and provider roles to meet these standards when staffing for outings in the community.","Multiple_Choice__101":"2","Free_Text__102":"The crowd size, unfamiliarity with the State Fair and the person, impacted staff losing sight of the individual. When the staff lost sight of the person, his attention was divided between his 10-year-old son and the person. \r\n\r\nAnother contributing factor to losing sight of the person was that staff did not perceive a risk of losing the person because there was no elopement history. Therefore, staff felt comfortable bringing their son. Staff also knew the person\u2019s high level abilities to be independent and capabilities to navigate the scooter, which further supported their decision to have divided attention between the person and their son.","Multiple_Choice__103":"3","Free_Text__104":"The provider was experiencing a staff shortage and would not have been able to find another staff to go to the fair with the person.  \r\n\r\nAn industry wide staffing shortage impacted the providers\u2019 ability to hire and retain part-time, intermittent, 1:1 activities staff. The HCBS Rule on Community Inclusion and Person Centered Planning and Person Centered Thinking influenced the Case Manager and provider roles to meet these standards when staffing for outings in the community.","Multiple_Choice__105":"0","Multiple_Choice__107":"0","Multiple_Choice__109":"2","Free_Text__110":"The Case Manager approved the decision not to require a line of sight on the person while out in the community. The person\u2019s history of challenging behaviors influenced the Guardian\u2019s directive to the Case Manager not to include any alone time in the CSSP and the Case Manager's decision to include a 1:1 staffing ratio on public outings in the CSSP. This requirement was an influence on how the provider selected staff for the outing .","Multiple_Choice__111":"0","Multiple_Choice__113":"0","Multiple_Choice__115":"2","Free_Text__116":"The provider has a policy that allows staff to use judgment\/interpretation of the Coordinated Services & Support Plan (CSSP) as long as staff is attentive to the persons needs without direct line of sight. The provider allows this room for staff judgment because it gives staff the space and ability to support each person as they need and choose.","Multiple_Choice__117":"0","Multiple_Choice__119":"0","Multiple_Choice__121":"1","Multiple_Choice__123":"1","Multiple_Choice__125":"0","Yes_or_No__432":"Yes"}