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Why It Happened

In the Field · Episode 4

Why It Happened

Simone looks at the schedule. Luis wasn't the only one doing bedtime alone.

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Key takeawayFind the real causeWhen a mistake happens, look for why: staffing, schedules, training, equipment, unclear plans. Ask other staff how things really work. Coach the individual, and fix the system problems you find, raising them to leadership when you can't solve them yourself. Blame alone makes the same mistake happen again.

In this scene

Simone: Four nights out of five, there's one staff on the floor at nine. Every bedtime transfer happens then.

Hannah: You wanted to see me? Is this about last night?

Simone: You're not in trouble. When you're on alone at bedtime, how do transfers happen?

Watch the episode to see what happens next.

Questions to think about

  • A shortcut keeps happening at bedtime. You look at:
  • Hannah says everybody does it. This tells you:
  • You can't fix the staffing yourself. You:

About this series

For supervisors of direct support staff: real observation in the field, stopping unsafe care, feedback that lands, finding the real cause, hands-on coaching, coaching new staff, concerns you must report rather than coach, rebuilding trust, making it safe to speak up, and following up. Follow your agency's policies and your state's reporting rules. See the whole series

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