Elopement is one of many risks to older adults with dementia. Even in the early stages of dementia, wandering behavior can be dangerous as seniors may be unable to find their way home or recognize hazards. Family members caring for someone with dementia at home often learn about this dangerous behavior when their loved one leaves home and gets lost. In fact, the fear of their loved one escaping and getting hurt is often a large factor in deciding to place a family member in a nursing home.
Families trust nursing homes to protect their loved one and give them the best care possible. One of the last things most families ever anticipate is a phone call from the facility informing them that they lost their loved one. Sadly, it’s more common than many would believe.
Nursing home elopement is often the result of understaffing in nursing homes and inadequate elopement precautions. Nursing homes have a duty to protect the safety and well-being of residents which includes preventing elopement and the factors that allow it to happen. If your loved one has been hurt after leaving a nursing home, a nursing home elopement attorney at Berman & Riedel, LLP can help you hold the negligent facility accountable.
Table of Contents
What Is Elopement in a Nursing Home?
Wandering is normal and expected behavior among residents with dementia and it can even be beneficial. With an adequate wandering management program in place, residents that can safely wander can get exercise and may have less anxiety. Elopement is a specific type of wandering in which a resident leaves the facility unsupervised.
Dementia wandering comes in many forms which can be categorized by the intent and cause. Types of wandering include:
- Environmentally-cued wandering – a response to surroundings and cues such as a hallway serving as a cue to walk or a chair to sit, or wandering in response to something the patient sees or hears
- Reminiscent or fantasy wandering – attempting to go to a familiar place from the past
- Tactile wandering – patients using their hands to explore their surroundings
- Agitated purposeful wandering – occurs in patients who are frightened and/or confused, cannot be reasoned with, and may be combative
- Recreational wandering – associated with a need or desire for activity or exercise
- Elopement – the most dangerous form of wandering which involves wandering from home or a facility
Elopement in nursing homes is generally distinguished from other forms of wandering because it involves purposeful and often repeated attempts to leave an area and poses a serious risk.
What Is Elopement Risk and Which Nursing Home Residents Are a High Elopement Risk?
Nursing home residents with Alzheimer’s disease and related dementia disorders should automatically be considered at risk of elopement. Along with cognitive impairment or dementia, other risk factors for wandering and elopement include:
- Male sex
- Agitation or aggression
- Poor sleep
- Socially active and outgoing prior to illness
People with dementia may also exhibit behavior that indicates a high elopement risk, or a risk that they will try to escape the facility, such as:
- Stating that they are leaving or need to go somewhere
- Restlessness or agitation
- Disorientated by their surroundings
- Searching for something
Research has found several patterns in dementia patient elopement:
- Elopement is least likely to happen between 12 am and 7 am
- Elopement is a recurring issue. Around 72% of wandering residents who successfully elope try to do it again. 80% of nursing home elopement claims involve residents who are described as “chronic wanderers.”
- About 45% of elopement claims are filed within 48 hours of a resident being admitted to the facility
Assessing Elopement Risk
Residents should be assessed to determine their risk of elopement. There are many ways to define wandering, and the severity of a patient’s dementia may not be immediately apparent. A resident’s condition can also deteriorate which increases their elopement risk.
There are many tools that can be used to assess the risk of wandering:
- The Cohen-Mansfield Agitation Inventory (CMAI) is a seven-point rating tool to assess how often a patient displays any of 29 agitation-related behaviors, a major risk factor for wandering.
- The Rating Scale for Aggressive Behavior in the Elderly (RAGE) is used to rate the frequency a resident displays 21 types of aggressive behavior over a three-day period.
- The Neuropsychiatric Inventory (NPI) is a clinician-administered questionnaire used to score the severity, frequency, and amount of distress associated with 10-12 behaviors common in patients with dementia.
- The Revised Algase Wandering Scale (RAWS) is used specifically to determine the risk of wandering. RAWS-LTC is a version designed specifically for the long-term care setting and uses a 1-4 scale to score residents on 19 domains.
Dementia Wandering – Why Do People with Dementia Wander?
Wandering behavior is very common in people with Alzheimer’s disease and other forms of dementia. According to a study published in Psychogeriatrics, about 1 out of 5 people with dementia living in the community wander and 3 out of 5 dementia residents in institutional settings like nursing homes wander.
While the risk of wandering hasn’t been studied extensively between different forms of dementia, wandering or elopement risk does increase as cognitive impairment becomes more severe. It does seem to be more common with Alzheimer’s which commonly causes amnesia and spatial disorientation.
Dementia and wandering are complex and the reasons for the behavior aren’t well understood. There are many possible reasons for wandering behavior and several theories. It may be caused by a disconnection between regions of the brain responsible for motor, memory, and visuospatial functions. A PET study found a distinct pattern among patients known to wander as well as correlations between the types of wandering (such as pacing) and specific areas of the brain.
Wandering and exit seeking behavior may happen when a confused resident is:
- Unable to remember and follow instructions to stay or wait somewhere
- Dealing with a sudden change in their routine or surroundings
- Responding to something they see or hear
- Looking for something or someone from the past
- Trying to go home, even when they are home
There is no such thing as a dementia wandering stage. Wandering behavior can occur at any stage of dementia.
Consequences of Eloping – the Dangers of Patient Elopement
Not all wandering is dangerous or harmful for residents, but elopement, or actually escaping the facility, is incredibly dangerous. There have been many cases of elopement that have resulted in death. Residents with dementia who leave the facility are likely unable to find their way back, recognize dangers, or know how to get help (or that they even need it). This can lead to death due to exposure to the elements, drowning, a traffic accident, or some other hazard.
Sadly, a study of more than 300 cases of dementia elopement found that 30% of the people with dementia who eloped were dead when they were finally found. There is a 25% fatality rate for nursing home residents not found within 24 hours of elopement. This increases to 54% if they are not found within 96 hours.
Research has also found that nursing home residents prone to wandering are also at an increased risk of hip fractures. A study identified risk factors for hip fractures in nursing homes and found the most significant predictors are: female, impaired cognition, severity of dementia, wandering, able to independently walk and perform activities of daily living, diabetes, and easily distracted. About 36% of nursing home residents with a hip fracture die within 6 months and 17% previously ambulatory residents become fully disabled.
This is yet another reason for nursing homes to take elopement precautions seriously.
At a minimum, elopement from nursing home facilities can leave vulnerable residents frightened and confused for many hours. It can also cause them to miss critical medication that can worsen existing health conditions and lead to injury or worse.
What Is the Best Way to Handle Wandering Patients? – Elopement Precautions & Interventions
Wandering behavior itself is not a problem that needs to be eliminated: a wandering resident should be able to safely wander in the facility in a way that allows them to get exercise and alleviate anxiety. However, a nursing home facility has a legal duty to both provide a safe facility and prevent elopement.
Beyond assessing each resident’s elopement risk when they are admitted, a variety of elopement precautions can be taken that preserve resident rights and promote a safe wandering environment without restraints.
Adequate Staffing and Supervision
Understaffing in nursing homes is one of the biggest risk factors for nursing home elopement and nursing home neglect. Many cases of elopement from nursing home facilities are caused by inadequate supervision, understaffing, and overworked staff who simply do not have the ability to manage the number of residents they are assigned. Even the best monitoring bracelets and door alarms cannot overcome understaffing when there are not enough staff members to respond to alarms or implement protocols.
Locks and Alarms on Nursing Home Doors, Exits & More
It’s no replacement for adequate supervision and staffing, but equipping exits that residents should not be operating with alarms and locks (in compliance with fire codes) is one of the most critical nursing interventions for wandering residents. Depending on the resident’s mobility and risks, alarms may even be used on beds and wheelchairs.
Monitoring Bracelets for High-Risk Patients
For residents with a high elopement risk, electronic monitoring may be appropriate. The WanderGuard bracelet is one example. A WanderGuard nursing home bracelet contains a unique serial number and is activated wirelessly to provide location monitoring and trigger alarms and/or lock monitored doors with geofencing technology.
Adequate Protocols & Training
It isn’t enough for a nursing home to have adequate staff; they also have a duty to make sure staff have the adequate training and the facility has sufficient protocols in place.
Some areas that should be covered in training include:
- The importance of maintaining visibility of facility exits, especially when staff may be distracted or diverted like during shift changes or emergencies
- The need for increased vigilance for elopement attempts during the resident’s first week living at the facility
- How to conduct checks for resident whereabouts at regular intervals
- Ensuring staff understand that a reluctance or delay in reporting a missing resident is not acceptable
Nursing homes should not underestimate a resident’s ability to wander or elope. Even non-ambulatory residents in wheelchairs can wander and escape the facility without proper safeguards.
In the event a resident does elope, the facility should have missing resident protocols. Staff should be trained on these protocols and potentially even put through periodic missing resident drills. Basic protocols should include:
- A means of quickly internally notifying staff to initiate a response
- Assigning staff to specific areas of the facility and grounds to search
- How to conduct a systematic search and instructions to search immediate areas that are normally inaccessible or locked, roadways, parking lots, and ornamental ponds
- Notification of family members, facility management, and physicians
- Local police notification so they can assist with the search
- Documentation requirements for the actions taken at the time of the elopement and afterward
- Once the missing resident is located, protocols to follow including a complete medical evaluation, contacting individuals who were already notified, and an investigation into how the incident happened and what can be done to prevent another
Other Elopement Precaution Methods
Nursing homes with dedicated memory care units, or facilities that specialize in Alzheimer’s disease and other forms of dementia, often adopt creative solutions to the question of how to keep Alzheimer’s patients from wandering dangerously. Exit diversion strategies like disguising doors don’t just reduce the risk of elopement – they save residents from avoidable stress and reduce staff time spent redirecting residents.
The mere appearance of an hospital-grade exit door can prompt exit-seeking behavior. For some residents with dementia, an “exit” sign can be interpreted very literally as a direction.
Disguising exits will not work for all residents with dementia as it depends on the individual, the stage, and the severity of the dementia. However, methods like disguising doors or placing black mats can be very effective when combined with other precautions like alarms. Different types of dementia cause damage to the brain’s ability to process visual information, recognize objects, and judge distances. These methods of disguising exits and redirecting residents take advantage of these changes to visual processing:
- Reduced depth perception. Dementia patients often display trouble distinguishing between two- and three-dimensional scenes and typically interpret a black mat on the floor as a deep hole and avoid it.
- Reduced contrast perception. This can make it hard to perceive mashed potatoes on a white plate or a door painted the same color as the wall.
Door masking, such as disguising a door as a bookshelf or painting it the same color as the wall, should be done with care because it can affect exiting during an emergency. A local fire marshal can usually assist with interpreting safety codes.
Another method for redirecting residents and preventing elopement is setting up authentic-looking fake bus stops and shelters in common areas and gardens and adding benches in hallways. These additions attract wandering residents to sit and wait for a bus. This can prevent elopement while making it easier for staff to supervise them and alleviating stress or confusion that may have prompted their wandering.
Nursing Home Elopement Liability & the Duties of a Nursing Home
Nursing homes have a duty to provide adequate care, maintain a safe environment, and protect vulnerable residents from escaping. The duties of a nursing home include:
- Assessing elopement risk of residents when they are admitted
- Developing an elopement risk nursing care plan for residents at risk of elopement
- Maintaining a safe environment for residents that supports safe wandering, adequate stimulation, social interaction, and rest
- Instituting adequate interventions for wandering residents including non-tech and tech-based solutions that keep residents safe
- Creating a response plan and protocols to follow if a resident escapes
- Training staff sufficiently to recognize elopement risks and respond properly to elopement attempts or escapes
- Reporting elopement promptly to the resident’s family and authorities
The requirement to assess residents for elopement risk and develop a care plan is a federal law under the Omnibus Budget Reconciliation Act or the Nursing Home Reform Act of 1987.
While the facility must provide a safe, secure environment, any elopement precaution measure should be weighed against the rights of residents. This means residents cannot have their movement and autonomy restricted beyond what is necessary such as the use of restraints.
When a nursing home resident is allowed to escape, nursing homes can generally be held liable. Nursing homes must not only assess resident elopement risk and implement reasonable nursing home elopement precautions, they must also take prompt action to locate and return missing residents.
At-risk nursing home residents should not be allowed to simply walk out of a secure facility. It is almost always the result of nursing home negligence, whether the facility failed to assess the resident, did not adopt adequate precautions, or did not have adequate staff levels or training to supervise residents.
Schedule a Consultation with a Nursing Home Elopement Attorney
When California nursing homes fail to ensure adequate supervision, elopement risk assessments, and security, they may be liable under state and federal law if their negligence results in a resident getting hurt. If your loved one has been allowed to leave the facility unsupervised and suffered injury or even death, an experienced nursing home elopement law firm can help you seek justice and hold the facility accountable.
Berman & Riedel, LLP represents nursing home residents and their families throughout California. Our law firm specializes in cases of nursing home negligence and abuse with case results that speak for themselves. Contact a nursing home elopement attorney at our law office today to schedule a free consultation to discuss your case.