“Never Events”

Dangerous situation on city roads

As previously reported, PeaceHealth St. Joseph Medical Center in Bellingham, Washington was found to be out of compliance regarding the use of restraints, seclusion, isolation, patient care and emergency services in an investigation by the Washington State Department of Health.

One critical issue that this investigation missed was the issue of elopement of a vulnerable adult who ran out of the hospital, barefoot and in scrubs, and was later found over 2 miles away.  This event is called a “Never Event” by the Patient Safety Network of the US Department of Health and Human Services.

Patient protection events
Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person
Patient death or serious disability associated with patient elopement (disappearance)
Patient suicide, attempted suicide, or self-harm resulting in serious disability, while being cared for in a health care facility

It is clear from the medical record, investigation, reports from local police and family/guardian that the hospital was well aware that this patient was a vulnerable adult under a guardianship yet when this person left the hospital and the hospital staff was well aware that he ran out of the exit while being escorted to the restroom,  the hospital did not notify anyone.  Does this hospital have a policy regarding missing patients such as a special code called?  That is the standard of care and apparently this hospital does not practice up to the standard of care.

I have contacted the DOH team which did this investigation asking questions why this critical event was missed and not addressed in the investigation.  I am still awaiting a response.

I am so thankful that the outcome was not what we see in the photo below – but given the circumstances, this was a real possibility by the “Never Event”

Body of a young child covered by a sheet“.

Malika is lost!



Today when I picked up my son at his house to take him to the doctor, he was very excited to tell me about things he had learned.  Unfortunately, he doesn’t understand what it means or how scary the situation is – to him it’s exciting news because someone he knows was on TV.

Malika lived in my son’s supportive community – “Malika moved”  “Malika on TV”  “Malika lost”  was the news that he told me.

Malika has now been found:

A 17-year-old mentally disabled girl who ran away from a Bonney Lake-area group home Sunday was found safe this morning, according to the Pierce County Sheriff’s Office.

Auburn police found Maliika Andrus at a Starbucks coffee shop after a witness reported seeing her. She was taken to a local hospital for evaluation and will be returned to the group home later today.

Staff last saw the teen early Sunday morning at the facility in the 18400 block of South Tapps Drive East. Deputies believe she tampered with the alarm on the window of her room so she could escape

Washington State passed a harmful law in 2011 which prohibits “youth” 21 and under from admission to the supportive community of our state’s Residential Habilitation Centers (RHCs).  They may be allowed short term admission in crisis situations if no other alternatives are available.  The only alternative is the new 3-bed crisis stabilization unit – that is hardly sufficient to safely care for our youth.   Malika was most likely admitted on a short term stay and that had expired.  Our state had to evict her from the safe community to a group home.  Alarms are not nearly as safe as alert human eyes and presence.
This law puts all our youth with disabilities and their families at risk.  We need to overturn this law to help prevent harm to our loved ones.


An Education for ALL

My current advocacy situation is teaching me alot – I’m sorry to say this because a family is being destroyed by the system which is supposed to help us.  But what I am learning is part of an education that we all could use so that we can be prepared for these very same things to happen to any one of us in advocating for safe and appropriate care for our children.

Mary, the mother of a 16 year old boy with autism is in crisis – all because she complained about inappropriate care which was causing health problems for her child, limiting her ability to visit with her child and her desire to have his placement changed from the group home to a residential habilitation center again.  The community experience was not working out and in addition to the above concerns there are also issues of alleged sexual abuse.

Mary, after discovering another issue of false documentation in the group home log, she had her son taken to the hospital.  She called an ambulance because she knew it was not safe for her to drive him.  She followed.  At the hospital, Mary was met by a CPS caseworker.  Mary felt relieved, thinking that they were there to look into the issues of the home.  Mary could not have been so wrong.  CPS was there because the Seattle Police had been called for an emergency dependency issue.  At this point we are unsure who made that first call but the records are being subpoenaed.

Mary’s son was taken into “protective custody” (sent back to the group home where the alleged abuse and neglect occurred) because Mary is unable to care for her son due to:

1. Lack of supervision

2.  Mother’s inability to safely care for sons’ needs (mental health and basic care)


Now, these issues were never in question.  This boy had been in an RHC and then was moved to a group home.  It is clear from the history that the mother cannot safely care for her son and she has not disputed that.  She is seeking safe, appropriate care.    When she took  her son to the ER, she made it clear that she wanted him safe and out of that home (she had been trying to have her son moved for about 1 year) and ALL involved knew this.  She was not running away, she was not taking her son to an undisclosed place, she was not disappearing – she was taking him to a safe place.

This boy has a history of elopement (how many of our kids with autism exhibit this behavior as part of their “normal”?)  Well, the boy ran out of the emergency room and no one could find him.  Security finally did.  The CPS caseworker wrote this up in a way to make it seem as if this boy ran away from his mom because she was not able to care for him or that she was hurting him.  The CPS caseworker either does not understand what “typical” behaviors for kids with autism are or she was writing her report to implicate the mom for something that she did not do.  Either way, this is frightening to know that our lives could be thrown into crisis by a CPS caseworker who either has an agenda or does not know what is typical for kids with certain diagnoses.

CPS has now filed an Emergency Dependency and by court order now Mary is only allowed supervised visits with her son.  CPS can only afford to pay for a supervisor for 2 hours a week so even though the court order says she can have up to 5 visits per week, she only gets 2 hours of visit time.  That is until the background checks for her other appointed supervisors come back and they are able to take the CPS class to learn what is required to be a “supervisor” of a visit.

This is tearing this family apart – as if they didn’t have enough already.

CPS is looking at this mother’s complete history to see if she is” mentally fit” to care for her son.

Now, guess what.  The mom has had a history of depression which was later changed to Post Traumatic Stress Disorder.  What mom of a child with autism does not have some sort of anxiety/depression/PTSD or some health issue related to high levels of stress?  Because the mom has a “mental health” history, she is now having to prove that she is not psychotic or mentally unstable.

The mom had a previous CPS case.  The CPS caseworker wrote in the court petition “Mom refused to pick up child from hospital when he was discharged – Case unfounded”  But, it doesn’t matter, since she has a history, this is looked at.  In fact in this case, the mom called CPS because she didn’t want to get charged with abandonment.  She had an eye injury and partially detached retina from being stabbed in the eye by her son.  That was why he was in the hospital.  She is a single mom and was still in the process of healing with that eye injury and could not safely take care of her son when he was ready to be discharged.  For being a loving and caring mom and trying to do the right thing, she is being viewed as a criminal.

This scenario is horrific.  This is going on right now.  This scenario should NEVER have happened.  But once CPS is involved in an emergency dependency, there seems to be no stopping or turning back.  So in the meantime this family is destroyed, the boy is confused about why he can not have his regular and often visits with him mom and sister, why he can’t go to church, why he can’t to play basketball with his mom, why he can’t go to their weekly dinner at Applebees’ with his mom and sister.

It’s hard enough for families to work with one system (DDD) but with CPS now in charge of this case, DDD has taken a back burner until the dependency case goes to trial which could be 2 more months.

And still, the mom is very concerned and worried about her son’s health and safety.

I hope that no one else experiences these abuses of families by the systems which are set up to protect our kids.  We are not criminals!