{"Short_Answer__76":"201901929","Date__77":"05\/22\/2019","Multiple_Choice__78":"Jill Tilbury","Multiple_Choice__79":"Kristie Pittman","Short_Answer__80":"MRCI","Short_Answer__81":"Cathy Groebner","Short_Answer__82":"cgroebner@mymrci.org","Multiple_Choice__84":"Elopement","Multiple_Choice__85":"Blue Earth County","Date__86":"03\/19\/2019","Free_Text__87":"\"Wednesday March 13, 2019 at approximately 1:40pm, staff 1 noticed VA leave the Department 123 work area. Staff 1 stepped outside the room and saw VA going into the women\u2019s bathroom located off of the production floor nearest to Department 123.  Staff 1 checked on VA at about 1:45pm and saw that VA was in the handicap stall with their green jacket off.  Staff 1 asked if VA was OK and they replied \u201cyeah\u201d and also asked if VA needed anything and they said \u201cno\u201d.  Staff 1 then went back to that same bathroom to assist another individual at approximately 1:50pm and VA was still in the same stall.  Staff 1 went back to the room at about 1:55pm.  It should be noted that the VA had been diagnosed with a mild UTI on Sunday 3\/10\/19 and was sent home early on Monday 3\/11\/19 due to them not feeling well.  VA also came in late on Tuesday, 3\/12\/19.  \r\n\r\nVA has eloped in the past, VA takes her lunch box with her.  Because of that, VA is required to leave the lunch box in the Team Leader\u2019s office.  At approximately 2:00pm, staff 1 notice VA\u2019s lunch box was still in the office.  Support Specialist Staff 2 went to that same bathroom that VA was in approximately 2:05pm and that VA was no longer in the bathroom.  A bus drive for the day program was driving the buss back to the program and notice someone in a green jacket standing in the street on Map Drive around 2pm.  There are no sidewalks on Map Drive.  Staff recognized the person as the VA and immediately called her supervisor at the program. And drove back to where the VA was walking.  It was reported that two \u201cgood Samaritans\u201d pulled over and stopped the VA on the sidewalk along stadium drive, which is the road that connects with Map Drive, and started walking with her back to the program until the staff arrived.  \r\n\r\nAt 2:07 the Supervisor received a phone call from the transportation supervisor stating VA was found walking on the sidewalk along Stadium Drive and was being walked back to the program\u2019s building.  The program supervisor ran outside and saw VA with about four other program staff walking with VA.  The supervisor walked alongside VA all the way back to the office and the VA waited in the office until was time for VA to board the bus to go home.  While the office, VA was ask if VA thought what happened was safe and the VA said, \u201cNo\u201d. The VA was asked why it wasn\u2019t and safe and the response was \u201cI could get hurt\u201d. Supervisor asked VA if it will ever happen again and VA shook their head \u201cno\u201d. Supervisor walked VA to the bus and fastened seatbelt and sat patiently until the bus departed.  \"","Multiple_Choice__96":"1","Short_Answer__91":"Staff didn\u2019t continuously monitor the person in bathroom and the person eloped without being seen","True_or_False__94":"Yes","Date__97":"07\/10\/2019","Free_Text__98":"\"VA has worked at the employment program for 10 years and the staff interviewed reported they have worked with her for most of that time.  Over this 10 years the VA lived with an aunt, then in an adult foster care setting (near her employment program) and at the time of the incident was living in an apartment.  \r\n\r\nVA enjoyed coloring\/crafts, being outside, working, having attention and encouragement from staff.  VA enjoyed food (lunch at work and wouldn\u2019t necessarily heat up a meal that typically would be a meal to heat up).\r\n\r\nVA has a staffing ratio at the employment program of a 1:3, most individuals there have 1:6 or 1:7.  At home VA had a 2:1 staffing ratio.  The 2:1 at home was higher because VA was more physically aggressive at home than at work.  Less aggression towards male staff-staff interviewed stated VA has less male staff at residence than at the employment program.  \r\n\r\nThe employment program has 200 individuals in their facility and approximately 45 in the area where VA works.  The day of the event there was 7-8 staff in the area for all of those individuals being served.  \r\n\r\nThe elopement protocol at the employment program was for the staff to have eyes on VA, except in the bathroom and just do 5 minute checks.  Keep the lunch and duffle bag in the supervisor\u2019s office.  VA would have no antecedents prior to elopements or other incidents of maladaptive behavior (this day was no different.  The team agreed to this plan including the guardians (parents).\r\n\r\nVA works at the employment program Monday-Friday from 9am-3pm and typically VA shows signs of being done with work at around 2pm.  The day of the incident the VA had arrive late or had not been ready when the bus arrived to pick her up.  This was a common occurrence.  \r\n\r\nWhen at work the VA was a great worker completing piece work on the work floor.  That day there was not a lot of work available and the group had been doing other craft activities (VA enjoyed).  It is believed that VA had a possible UTI infection and VA had a history of GERD\/esophagus issues (causing her to vomit and cause pain), however VA could not verbalize their needs all of the time.  Verbal skills were limited.  Over the time VA worked at the employment program they were able to get her to improve her verbal skills by encouraging VA to use her words.  If she were sick and she was about to vomit VA would attempt to express this to the employment staff and sometimes ask them for a Tums.  \r\n\r\nThe VA did not take the duffle bag or lunch when the elopement occurred which typically the VA would not have left the building without either of the bags.  The VA never was able to explain the reason for elopement, however the staff believe there is a Kwik Trip nearby that was the direction VA was headed and her previous residence was near the employment program.  VA did things with no antecedents and would do things for attention.  The staff believe potentially VA was not feeling well and potentially wanted to go outside because VA really enjoyed being outside.  Staff went outside after receiving phone call from transportation company and got the VA from the Good Samaritan that was walking with VA.  \"","Free_Text__100":"The staff not continuously monitoring the person in the bathroom was impacted by the staff adapting the person\u2019s supervision protocol to allow for privacy in the bathroom.  It is the providers practice to allow all of the individual\u2019s privacy in the restroom as this is influenced by societal norms.  The other factors contributing to adapt the protocol the day of the event was the individual was not feeling well, typically towards the end of the day this individual participates in work less (the time of incident was at the end of the work day), and there is a history of the person taking a long time in the restroom.  Further influencing the person\u2019s ability to elope without staff noticing was the staff did not see the historical antecedent the person would display before eloping because in this case the individual eloped without taking their lunch bag out of the staff\u2019s office.  Additionally, during this event there were multiple staff checking on the individual since in this setting there is not a specific staff assigned to one individual person working.  This process is the norm for the department as it is shaped by the support plan stating the need for a 1:3 staffing ratio. Thus the ratio allows the county to manage the budget allocation they are given by the state and federal allocations which is determined through the legislation.  Overall legislation determines the rates that are set which then is strengthened by MNCHOICES to determine the needs are met, thus to create the staffing patterns for the provider in the support plan.","Multiple_Choice__101":"2","Free_Text__102":"The other factors contributing to adapt the protocol the day of the event was the individual was not feeling well, typically towards the end of the day this individual participates in work less (the time of incident was at the end of the work day), and there is a history of the person taking a long time in the restroom.  Further influencing the person\u2019s ability to elope without staff noticing was the staff did not see the historical antecedent the person would display before eloping because in this case the individual eloped without taking their lunch bag out of the staff\u2019s office.","Multiple_Choice__103":"0","Multiple_Choice__105":"0","Multiple_Choice__107":"0","Multiple_Choice__109":"0","Multiple_Choice__111":"0","Multiple_Choice__113":"0","Multiple_Choice__115":"3","Free_Text__116":"\"The staff not continuously monitoring the person in the bathroom was impacted by the staff adapting the person\u2019s supervision protocol to allow for privacy in the bathroom.  \r\n\r\nAdditionally, during this event there were multiple staff checking on the individual since in this setting there is not a specific staff assigned to one individual person working.  This process is the norm for the department as it is shaped by the support plan stating the need for a 1:3 staffing ratio.\"","Multiple_Choice__117":"0","Multiple_Choice__119":"0","Multiple_Choice__121":"0","Multiple_Choice__123":"2","Free_Text__124":"The staff not continuously monitoring the person in the bathroom was impacted by the staff adapting the person\u2019s supervision protocol to allow for privacy in the bathroom.","Multiple_Choice__125":"0","Yes_or_No__432":"Yes"}