Case Types
Elopement
Any good nursing home should understand that elopement is a major safety problem that must be prevented. There are numerous steps nursing homes can take to prevent residents from wandering away.
What is elopement (wandering away)?
Elopement is a fancy, legal term meaning “to wander away” from a safe space. Elopement occurs when a nursing home resident leaves the facility’s premises or a safe area without authorization and / or the necessary supervision to do so.
Why is elopement from a nursing home dangerous?
Elopement of nursing home residents can, and often does, result in death. Deaths from elopement include being struck by a vehicle or train, falling and suffering a fracture or head injury, exposure to heat or cold (including dehydration, heat stroke, and freezing to death), drowning (usually in ditches, pools, and ponds), falling down stairs, or traveling into another resident’s room where a confrontation may occur. Sadly, these are all common causes of injuries and death for nursing home residents allowed to wander away from the facility.
The longer a patient is missing from a nursing home, the more likely the patient is to die.
Allowing A Resident to Wander is Neglect
A nursing home must never allow a nursing home resident to leave the premises unsupervised when it is not safe to do so. A nursing home must never neglect a resident. “Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.” 42 CFR 483.5.
To allow a resident to leave the premises unsupervised when it is not safe to do so is neglect. The nursing home is responsible for any injuries the resident suffers.
Nursing homes must have enough staff to prevent wandering
By law, nursing homes must be “sufficiently staffed.” This means that they have adequate staff to care for each and every resident, and no resident is needlessly exposed to harm.
Many wandering events stem from poor staffing and poorly trained staff. Residents who wander are typically more complex patients than those who do not wander. By complex, I mean that they have more medical conditions, require greater supervision, and often have behavior problems. Complex patients require greater supervision than less complex patients.
Many wandering events occur during periods of poor staffing. These are (1) the late-afternoon hours or early evening (these are also times when residents are becoming most confused called “sundowning”), (2) mealtimes when staff are moving many residents and delivering food and therefore cannot supervise residents, and (3) when nursing homes generally are understaffed (these are typically 1-star and 2-star facilities as rated by Medicare).
Nursing homes understand that there is a direct relationship between good staffing and safe residents.
Who’s at risk of eloping or wandering away from a nursing home?
Some nursing home residents are more at risk of wandering away than others. For example, some patients may have their wits about them, and there is almost no risk that they will wander away.
Patients most likely to wander include patients with memory disorders like dementia, Alzheimer’s, or brain injuries caused by trauma or stroke.
Alzheimer's and Dementia Patients
Dementia and Alzheimer’s are common reasons that people move into nursing homes. 1 in 5 patients with dementia wanders. As many as one-third of nursing home residents with dementia wander. Lai CK, Arthur DG. Wandering behaviour in people with dementia. J Adv Nurs.2003;44(2):173-182.
Part of the reason patients with dementia wander or elope is that they are more sensitive to their environment.
It is well known that people with dementia have a lower threshold for stress, and their ability to cope with internal and environmental stressors continues to erode as the disease progresses. Wandering is a symptom of an underlying mental or physical problem. Behavioral symptoms like wandering can emerge when internal discomfort, especially when coupled with external demands (e.g., a noisy environment), exceeds the individual’s threshold. That is, the resident cannot cope with the stress of the environment.
Dementia patients with unmet needs, such as the need for toileting assistance or the need to find a place of safety or someone familiar, may be more prone to wandering. The more a person declines cognitively, the more their behavior is affected by their environment.
Risk factors for dementia patients, include:
- New or unfamiliar environment
- Recent medication changes
- Being left alone without supervision
- Changes in schedule / routine
- Spatially disoriented to familiar cues
- Demonstrates a desire to engage in past practice (e.g., going to work or visiting a relative) or expresses a desire to “go home”
Other medical conditions that cause wandering
Wandering and elopement are not limited to Alzheimer’s and dementia patients. Other medical conditions can cause wandering. These conditions include infections, Parkinson’s disorder (end-stage), stroke, autism spectrum disorder, and Down syndrome.
Unlike dementia and Alzheimer’s–which cause problems with memory–there are numerous reasons why these other medical conditions can cause wandering. Patients with end-stage Parkinson’s disorder sometimes wander not necessarily because of the syndrome itself, but because they develop psychosis from taking medications for years. Likewise, infections can cause mental status changes that may result in a resident believing they are somewhere different from where they really are. Nursing homes are required to know which patients are risk for wandering, regardless of the underlying cause of the behavior. The fact that wandering may have been caused by something other than Alzheimer’s or dementia is no excuse.
Stroke and Traumatic Brain Injuries
Stroke and traumatic brain injuries (such as after car crash or falling injuries) can affect various parts of the brain. Some of these areas may be responsible for memory, judgment, or decision-making. As a result, some individuals recovering from a stroke or traumatic brain injury may exhibit many of the same wandering behaviors as patients who have dementia and Alzheimer’s.
A nursing home caring for such a resident must put precautions in place to prevent wandering, regardless of what is causing the wandering.
Patients with Psychological Conditions
Psychological diseases can cause confusion, agitation, forgetfulness, and numerous other symptoms that can increase the likelihood that a patient will wander. Oftentimes, psychological conditions and diseases are not the only conditions an elderly person is suffering. More often, an elderly person who has a diagnosed psychological condition also has other underlying medical conditions. Further complicating matters, many elderly individuals take medications that can increase confusion, forgetfulness, and agitation.
A good nursing home must take all of the conditions into consideration when developing an adequate plan to prevent wandering.
Other Risk Factors for Wandering
Older age
While not all older people will wander, the risk of wandering increases as a person ages.
Male sex
Poor Sleep Patterns
Agitation and Aggression
A resident’s history of agitation and / or aggression is a risk factor for eloping or wandering away from a nursing home.
New residents
Residents are most likely to attempt to exit a nursing home in the first 48 hours. A resident who is newly admitted to a nursing home is at risk of eloping or wandering away from the nursing home.
Socially Active and Outgoing Lifestyle
For people who had a socially and outgoing life, a transition to a nursing home can be confusing and frustrating. The result is that the resident may become restless and / or agitated and attempt to move about to socialize in unsafe ways. The nursing home must limit this agitation by offering stimulating activities.
Patients with Prior Wandering or Elopement Behavior
A history of wandering is a risk factor for additional wandering and provides a clue that additional health providers must ask questions, such as:
- When did the wandering behavior begin and how frequently does it occur?
- Is it more frequent in daytime hours or at night?
- Is the wandering associated with other factors, such as noise or discomfort / pain?
- What type of travel pattern is exhibited (random, pacing, lapping)?
- Does the wandering appear purposeful?
How do nursing homes prevent residents from eloping or wandering away?
A nursing home must never allow a nursing home resident to leave the premises unsupervised when it is not safe to do so. A nursing home organization must actively take steps to prevent elopement. Some of the possible steps are listed below.
Risk factors for dementia patients, include:
A nursing home must determine which residents are at risk for elopement. A nursing must never ignore a resident’s risk factors for eloping. Risk factors for eloping include: physical, emotional, psychological, and environmental factors. Risk assessments must be conducted on the day of admission to the nursing home, quarterly, and anytime changes in behavior or cognition occur. These assessments are required by federal law. Because most elopement occurs within 48 hours after admission, it’s important that facilities conduct risk assessments as soon as possible.
There are numerous different types of assessment tools that can be used to assess a resident’s likelihood to wander. Each facility may have their own process for assessing residents at risk for wandering or elopement. A variety of tools may be used to identify a resident at risk for wandering or elopement; however, whatever tool is used, the following questions should be asked:
- Is the resident independently mobile?
- Is the resident cognitively intact?
- Does the resident have competent decision-making capability?
- Does the resident wander?
Does the resident have exit-seeking behavior? - Is there a past history of wandering or exiting a home or facility without supervision?
- Does the resident accept their current residency in the facility?
- Does the resident verbalize a desire to leave (e.g., “I want to go home”)?
- Has the resident asked questions about the facility’s rules about leaving the facility?
- Is there a special event or anniversary coming due that the resident normally would go to?
- Is the resident exhibiting restlessness and / or agitation?
Assessments are only good if they translate into action. After assessing the resident, the nursing home must determine what is causing a resident’s risk of wandering off and how to best prevent it.
Analyze what is causing the resident to wander.
Before a nursing home or assisted living facility creates a plan to prevent elopement, the nursing home must analyze and understand why the resident is attempting to leave in the first place.
There is usually a reason for a resident walking around or attempting to leave. These can include boredom, confusion, frustration, trying to learn about a new environment, or repeating patterns from their past (e.g., a lifelong security guard may attempt to walk around the building believing that he is carrying out his work).
For example, a resident may be new to a nursing home and may simply be walking around the facility–including both in and outside the facility–because it is new and unfamiliar. Another resident may not understand that he or she now lives at the facility and walks out in an effort to go home. Another resident may not have a strong grip on their current reality and may leave the facility because he or she believes that they are going to work.
There are numerous reasons that a person may want to leave a facility, and the best way to prevent this from happening is to address the root cause.
Intervene to prevent the resident from wandering off
A nursing home must implement interventions to prevent elopement that are consistent with the resident’s needs, goals, and plan of care.
Patients with Psychological Conditions
- Staff must supervise and perform frequent checks on the resident. A secured Alzheimer’s / Memory Care Unit is best for those individuals at high risk for wandering / elopement.
- Staff must closely monitor a resident following a room change or change in roommate.
- Staff must exercise increased vigilance when a resident verbalizes that he / she is “going home” and when exit-seeking behavior is observed.
- Staff must exercise increased vigilance during the first 48 hours after admission to the nursing home.
Security systems
- Electronic equipment such as bed and door alarms, video cameras, and resident tracking devices help prevent wandering and elopement. These devices reduce the both the incidence elopement and severity when they do occur.
Strategic Placement of Rooms
- For residents who wander, their rooms should be placed in the middle of a hallway, away from exits, and in an area where they are frequently observed by nursing.
- For residents who wander, their rooms should be placed away from stairwells, and all areas containing potentially harmful items (e.g., kitchens, janitor closets, mechanic shops, and areas of low light) should be inaccessible.
Secured units
Nursing homes must ensure that residents at high risk for wandering are secured in units that promote their safety and prevent them from leaving unsupervised.
- Exit and Alarm Systems
- Exit doors should be secured with alarms or keypads that are tested daily / weekly according to manufacturer recommendations, and those checks should be documented in a log book.
- The nursing home’s interior stairwell doors should be equipped with alarms reporting to the nursing station.
- All alarm systems should be connected to a central alarm system and include the ability to monitor elevator access. If alarms are disengaged (i.e., for repair or delivery), staff must secure the area to prevent access.
- Nursing homes can equip residents with a transmitting wristband device that alerts staff members when the resident approaches and even locks doors as the resident approaches.
- Elevators
- Elevators should be locked and monitored, requiring a key or passcode for access. An unmonitored and unsecured elevator is a danger to patients.
- Windows
- Windows should be secured so they cannot open fully. It is appropriate to have windows that open slightly to permit ventilation, but they should not open so much that a person can exit through the window or fall out of the window.
- Motion Detectors
- Motion detectors that turn on lights prevent residents from stumbling in the dark. Motion detectors also alert staff that a resident is up and moving.
Facility Design
Some memory care units may encourage residents to safely wander around the facility. These units, for example, may have “bumpers” on the wall that permit residents to bump into them without being injured.
Some memory care units have rounded hallways with no dead ends or corners. Dead ends encourage leaving. Corners encourage turning. Rounded hallways encourage more walking and because eloping usually involves staying on a continued path, this is considered safe.
Nursing homes may paint doors to look like walls so they look like one continuous scene. These illusions discourage leaving. When the doors and walls look similar, residents attempting to exit are discouraged.
Activities
Ongoing activity programs can offer stimulation to residents and minimize aimless wandering behaviors.
Resident Identifiers
Nursing homes should maintain behavior logs to document wandering tendencies. Once these behaviors have been exhibited, the potential for elopement increases.
Monitor the interventions to see if they’re working
A nursing home must routinely monitor interventions to make sure they are working. If the interventions are not working or will not prevent elopement, the nursing home must modify them to prevent elopement.
Provide a safe environment
By law, nursing home residents have a right to a safe environment. It is the nursing home’s job to make sure that right is not violated. A safe environment is one that a resident cannot wander away from. To put it another way, if a resident can wander away from a nursing home undetected, it is not a safe environment.
Communication about the resident and policies
It is not enough to have policies. A nursing home must clearly communicate its policies to its staff and actively monitor its staff to ensure that those policies are being followed. A policy that is not being followed does no good.
Nursing home management must consistently communicate to all staff about resident at risk of wandering. This communication is not limited to nursing staff. Staff members from housekeeping, activities, dietary, and therapies can also participate in observing wandering residents.
Once a resident has been identified as being at risk for wandering and interventions have been implemented, everything needs to be documented in the resident’s chart and communicated to everyone involved with the resident’s care. The following documentation should exist if nursing homes are doing their jobs.
- Care Plan – The resident’s care plan, which lists all interventions that are used to prevent wandering.
- Assignment sheets – All direct-care staff need to know which residents are at risk for wandering along with the interventions in place to prevent wandering and injuries.
- Pictures – Pictures of known wanderers should be discreetly posted to alert staff to the potential for elopement.
- Check In/Check Out Logs – Logs should be used anytime a resident leaves the facility alone, with family or facility-planned outings.
Train the staff about the resident and policies
Nursing homes must train their staff and provide appropriate support and resources to assess residents for their risk of wandering and provide appropriate interventions to reduce the likelihood of resident wandering and associated injuries.
Nursing homes should teach staff to be especially responsive to residents with dementia who exhibit behaviors such as excessive walking, show signs of anxiety or agitation, or verbalize a desire to “go home.”
Nursing homes should educate their staff about documentation and reporting guidelines and procedures for responding to wandering.
Nursing homes must educate their staff about the medical and psychological conditions associated with elopement, the time of day when elopement are most likely to occur (late afternoon and evening hours when residents become more confused), what methods exist to prevent elopement, and how to respond if an elopement event does occur.
How do nursing homes respond when a resident is lost?
What should happen when a resident wanders from a nursing home?
Nursing homes must establish a clear plan for finding residents who have eloped as soon as possible. The longer a patient is missing, the more likely the resident is to die. In a series of studies out of Virginia, the researchers determined the following death rates:
- 25% of residents not found in the first 24 hours died;
- 40% of residents not found in the first 72 hours died; and
- 56% of residents not found in the first 96 hours died.
Koester RJ. Lost Person Behavior: A Search and Rescue Guide on Where to Look for Land, Air, and Water. Charlottesville, VA: dbS Productions LLC; 2008:165-169. www.dbs-sar.com/LPB/Dementia.pdf. Most residents typically died from hypothermia (freezing to death), dehydration (dying of thirst), or drowning–usually from falling into ditches or ponds.
Any plan for finding residents must clearly and unambiguously define which staff members are doing what, who they should contact, where they should look, and how to go about looking.
When residents elope, where do they go?
When residents elope, they don’t go far. In a recent report, 89% or residents who wandered with dementia were discovered within 1 mile of their residence. Koester RJ. Lost Person Behavior: A Search and Rescue Guide on Where to Look for Land, Air, and Water. Charlottesville, VA: dbS Productions LLC; 2008:165-169. www.dbs-sar.com/LPB/Dementia.pdf.
Residents travel the path of least resistance. Typically, residents will simply walk (or sometimes leave in a motorized wheelchair) on the simplest path. Usually, that means traveling a paved area, in a flat direction or downhill, until they run out of energy or simply succumb to the environment.
Do nursing home residents understand they are lost? No. Residents who wander and elope do not participate in their own discovery because they do not understand that they are lost. Accordingly, they are not looking to be found.
Calling out names for residents who have wandered off is pointless because they do not know that they are lost.
Effect upon the family
Elopement is a fancy, legal term meaning “to wander away” from a safe space. Elopement occurs when a nursing home resident leaves the facility’s premises or a safe area without authorization and / or the necessary supervision to do so.
Any good nursing home should understand that elopement is a major safety problem that must be prevented. There are numerous steps nursing homes can take to prevent residents from wandering away.
Representative Cases
Ohio
A 76-year-old resident was found several yards away from a northern Ohio nursing home. She was found dead after wandering out into freezing cold conditions at Hilty Memorial Home in Pandora, Ohio.
Ohio
A woman in her 80s with Alzheimer’s dementia moved into an assisted living facility after her physician learned that she woke every night and wandered. The facility placed her room near an open, unsecured stairway. The family was concerned, but the facility assured the family that they would routinely check on her to make sure that she was safe. The woman was found at the bottom of the stairwell with severe injuries and fractures.
Ohio
An elderly woman was a resident of a nursing home in Muskingum County, Ohio. She was admitted to the hospital with agitation, and then returned to the nursing home. Despite her history of agitation, dementia, and efforts to leave the facility, she was allowed to stay in a room on the third floor of a nursing home with windows that opened fully. She fell from the window suffering severe, painful injuries before dying.
Alabama
An 83-year-old female resident walked out of an unlocked door at a personal care facility around midnight. She fell into a watery pit at a construction area on the care facility’s grounds and drowned in the mud.
Colorado
In the middle of winter, a resident with Alzheimer’s Disease wandered away from the assisted living facility where he lived. His disappearance went unnoticed for three hours. He was finally found alive, face down in a field, according to a state report. Three months later, another resident wandered away from the same facility and was later found crossing a four-lane road.
Pennsylvania
$650,000 settlement: An 80-year-old Alzheimer’s patient wandered away from the defendant’s facility and was found four days later, drowned in a nearby creek. Washington – $700,000 settlement: A 67-year-old female resident died after being locked out overnight. She was an alcoholic, a smoker and severely underweight. She had previously recovered from throat cancer.
Missouri
The state cited a facility after the decomposed body of a patient known for wandering off was found, surrounded by beer cans and liquor bottles, in a ditch. The facility never notified authorities the patient was missing. Alabama – A 64-year-old assisted living resident with dementia was found drowned. The resident was outside the facility without permission, despite state rules that forbid the home from having residents with such afflictions.
Alabama
A 92-year-old assisted living resident broke a window, crawled out of his room and wandered across a parking lot into a field where he collapsed and died in freezing temperatures. The dementia-afflicted man was looking for his wife, who had been taken temporarily to a hospital.
Florida
A resident walked away from a nursing home, fell in a drainage ditch and drowned. The verdict resulted in $1.8 million compensatory and $4.5 million punitive damages.
Florida
A 92-year-old resident of Pinellas Park Care & Rehab Center fell down 10 cement stairs to her death. She was still belted to her wheelchair. The facility was dangerously understaffed, and there simply were not enough people in place to monitor the resident. The jury awarded $200 million.
