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The National Institute for Elopement Prevention and Resolution (NIEPR) defines

elopement as a resident leaving a facility without supervision and in a

potentially harmful situation due to cognitive impairment. Wandering is one

type of behavior that has been associated with elopement. Sometimes

residents of long-term care facilities walk around without a specific purpose

throughout the hallways of their building. This is an example of one type of

wandering behavior. There are some who believe that wandering behaviors

that occur within a secured facility can actually be a healthy behavior since it

increases exercise. The most dangerous type of wandering is when a resident

who is confused leaves the long-term care facility and wanders away without

returning. These residents need increased supervision and safe places that

they can wander freely.

The number of people with Alzheimer’s disease will greatly increase as the

population ages. An estimated 14% of people age 71 and older have some form

of dementia. Patients diagnosed with dementia are placed in residences that

are not specifically designed for dementia patients. Policies and procedures

that address the risks of those with cognitive impairments should be applied

across all clinical areas. One of the risks of cognitive impairment includes

possible elopement from the facility.

Approximately 60-80% of dementia diagnoses are due to Alzheimer’s disease.

There is a wide array of symptomatology relating to Alzheimer’s disease which

makes them at higher risk for elopement. Alzheimer’s disease occurs when a

healthy brain develops beta-amyloid plaques on the outside of the neurons and

tau tangles develop on the inside of the brain’s neurons. This causes the

synapses between neurons to be unsuccessful with transferring information

between the neurons. This process eventually leads to the death of the brain’s

neurons and is one component of what causes dementia symptoms to occur for

individuals diagnosed with Alzheimer’s disease.

Addressing the environmental design of a facility can help reduce behaviors

that help to diminish aggression and agitation. Utilizing environmental

interventions such as limiting the external stimulation and information

processing will help keep residents calm. Based on current research,

suggestions to help alleviate wandering behaviors include personalizing

resident room settings. In the past residents lived in regimented environments

and were at times medicated to prevent wandering. Today long term facilities

are moving to a more flexible environment. In a study published by Murphy and

colleagues in 2010, a wander garden was created to allow residents with

dementia to ambulate in a safe manner. This garden is a secure outdoor area

that provides residents with the ability to independently walk in a natural

outdoor setting.

Why do residents wander? Sometimes there are different reasons for

wandering, based on various stimuli that triggers the behavior. It is up to the

direct care provider to find out what stimuli triggers each of their residents to

wander. These triggers can include pain, the urge to urinate, or emotional

stressors. “Reminiscent wandering” occurs when a resident wants to reach a

familiar place in their past. Residents who become agitated or combative may

have very purposeful wandering which occurs when they are scared or

disoriented. In contrast, wandering may be a result when a resident desires

exercise or activity. It is important for direct care providers to document the

residents habits. Find out what triggers them to wander, such as pain, the urge

to urinate, or emotional stressors. This will help the staff determine where the

resident may go when they are confused or upset if they should elope. “Exit

seeking” behaviors are the most dangerous form of wandering. This occurs

when residents try to leave the facility unsupervised which may result in injury

or death.

The Alzheimer’s Association identifies three Care Goals for residents who

wander. The first goal is for direct care staff to help maintain the resident’s

mobility so that they can move about safely and independently. The next goal

is to assess and address the resident’s wandering behavior. Wandering could be

a result of the resident having unmet needs that require attention. The last

goal is to prevent unsafe wandering of residents.

Staff need to identify each resident’s risk for wandering; provide adequate

supervision; reduce triggers in the environment for wandering and

individualize interventions for each resident. Find out if your facility has

procedures for responding to elopement situations, and if one is not written

then offer to help with developing a protocol to address this type of situation.

Interventions to help residents who are at high risk for elopement should be

individualized to the specific needs of each resident. The avoidance of

physical restraints is recommended since it has not been shown to reduce

elopement incidence. Provide for the resident’s toileting and incontinence

care on a routine based on their individual patterns of elimination. This helps

reduce wandering behaviors that are due to unmet needs. Accommodate

bedtime and sleep rituals for the resident to help improve sleep and reduce

insomnia. Use a recording device of someone who is familiar to the resident

that they can listen to repeatedly as need to help provide them with comfort.

“Failure-Free” activities help reduce agitation by having them perform actions

that are comforting to them such as viewing older photos of people and places

that they are familiar with.

The need to reduce environmental triggers for wandering is helpful to keep

residents who are at high risk for elopement less agitated. Resident room

location can reduce the trigger for wandering by avoiding placing their room in

areas that have a lot of noise or high traffic. Keep the room location away

from a view of the stairs, exit doors, or elevators to reduce their thoughts

about walking over to them. If the resident has any suitcases in their room,

make sure that they remain out of view so they do not think about leaving the

facility. Place the resident’s bed in the best location to access the bathroom,

and make sure that orienting symbols are present to help guide them to the

bathroom.

After reducing the environmental triggers, the next step is to individualize

care with interventions to reduce wandering behaviors. Begin with asking the

resident’s family members if they know what may be causing the resident to

wander. If a reason is known, then specific interventions can be utilized to

help limit the wandering behaviors. If wandering is due to security issues, find

out what specific anxieties they have and reassure them of their safety.

Confusion can occur with any changes, therefore it is helpful to avoid room

changes. Interventions recommended by Smith & Buckwalter to assist with

reducing agitation for the resident with dementia include: sensory

enhancement, socialization, and structured activities. Sensory enhancement

includes use of aromatherapy, music, massage/touch therapy, and Snoezelen.

This includes the use of colored lights, aromas, gentle music, textured

objects, and breeze machines to create a soothing environment for the

resident’s senses.

Socialization-related interventions are important and include use of therapy

dogs, reminiscence with photos, videos and recordings of a personalized

conversation that includes the resident’s family. Structured activities can

include recreational activities such as craft projects, games or physical

activities. Reducing the resident’s boredom can help avoid agitation. Soothing

music can increase relaxation along with non-glare lighting. Patients that

wander should have a clear, safe path that loops within the facility. Staff

should walk with the resident whenever possible.

Engaging these residents in activities such as folding towels or sheets or

sorting harmless objects can help them focus on tasks instead of wandering. In

the evening, offer residents specific bedtime rituals to help them relax and

reduce wandering during the night. Toileting or incontinence care must be

addressed routinely to help limit wandering related to these issues.

Restlessness which leads to wandering can also be due to pain. Therefore,

make sure that the resident’s pain level has been assessed and provided

appropriate interventions as needed. urses should be aware of the specific

behavioral cues the resident expresses when experiencing pain.

Direct care providers should do a thorough assessment of the resident upon

admission. This includes identifying those residents who are at high risk for

elopement. Mental status changes should be documented upon admission

including memory problems, confusion or disorientation. Remember that an

excellent source of information is the resident’s family members. Therefore,

make sure that part of the admission assessment includes interviewing the

family members and any other caregivers that the resident had who can

provide more insight into their behaviors such as wandering or prior history of

elopement. Upon admission, if a resident is found to be at high risk for

elopement and wandering, then a plan of care to prevent elopement should be

initiated. There are four key components to risk of elopement for residents

from a long-term care facility. These components include: 1) the resident has

cognitive impairment such as dementia or Alzheimer’s disease; 2) the

resident’s skills for making decisions are poor; 3) the resident experiences

delusions, hallucinations or schizophrenia; 4) the resident has sight

impairments and may accidently leave the facility. Please view the video clip

on this slide which addresses orienting a confused patient and preparing their

room and bed.

In order to reduce the risk of one of the residents you care for having an

elopement incident, it is important that strategies to prevent elopement are

followed. Stefanacci & Haimowitz (2013) explain necessary steps to take to

help prevent elopement from occurring. The first step is to assess for the

resident’s elopement risk. If they wander, identify which type of wandering

behavior they exhibit. After their risk for elopement is determined, the next

step will be to develop a plan to make sure that the resident remains safe and

secure inside the facility using the least restrictive methods. There are many

electronic monitoring systems that can be used with today’s technology

advances to provide the surveillance needed for those residents who are at

highest risk for elopement. Some examples include: wristwatch transmitters,

pendant transmitter that magnetically locks the facility doors within a certain

range, and computerized network systems that monitor doors of the facility. If

a resident does find a way to elope from the facility, it is important that direct

care staff know how to react quickly to find the missing resident. Emergency

drills and situations of evacuations when there is chaos occurring in the facility

is an opportune time for the resident to elope. Review your facility’s policies

and procedures for how to properly respond when a resident has been

identified as missing. This should be located in the Emergency or Disaster

preparedness plan.

Here are some examples of elopement incidents and the consequences.

-- The first example includes a 64 year old man who had been diagnosed with

Alzheimer’s disease and depression had walked out of a hospital without being seen.

13 days later his body was found in an empty pond.

--The second example occurred when an 80 year old female nursing home resident

with Alzheimer’s disease was found lying on the ground outside of the facility. She

was conscious, covered with ant bites, and had sunburn. An ambulance was called

and she was treated in a hospital emergency department and later released. They

found-out that she had walked out of the facility’s hallway exit door and an alarm

sounded. One of the employees heard the alarm and looked outside the exit door.

The employee didn’t see anyone and assumed it was a false alarm. It wasn’t until 2

hours later that an administrator of the facility walked outside and found the

resident. This was a 60-bed nursing home facility with staffing that exceeded the

state requirements. A lawsuit was filed against the facility requesting $1 million by

the plaintiff. The first trial lasted 9 days and ended in a mistrial. The second trial

resulted in a hung jury. The third and last trial resulted in a decision in favor of the

nursing home. However, the facility had to endure many legal costs and staff

stressors with the multiple trials.

The last example occurred in July, 2007, when a Family Care center had a resident

with Alzheimer’s Disease who was allowed to walk around outside the facility

unsupervised and was hit by a car while backing-out. The resident died from the

incident. The facility received a Type A penalty and fined by the North Carolina

Division of Health Service Regulation.

On January 1, 2015, The Joint Commission’s new Sentinel Event Policy became

effective which includes a new policy identified as “Patient Safety Events.”

Sentinel events are patient-safety events (not primarily related to the natural

course of a patient’s illness or underlying condition) that reach a patient and

result in death, permanent harm, or severe temporary harm.

The new Sentinel Event process requirements will help to determine

contributing factors and the causes of sentinel events. The Joint Commission

categorizes elopement situations that lead to death or permanent or severe

temporary harm, as a sentinel event if the resident is in a care setting that

provides round-the-clock care. In the new policy, other types of patient-safety

events are defined; they include adverse events, no-harm events, close calls,

and hazardous conditions. If an adverse event occurs, the nursing leaders of

the facility will need to be notified immediately and initiate an investigation

into the situation with prompt action. Whenever a sentinel event occurs, it

signals the need for an immediate evaluation and response.

A higher level of supervision for elopement prevention should involve

maximum staff surveillance. This includes placing the resident in a room

within view of the nurse’s station; having the nurses check-in on the resident

regularly and during shift changes; and having 1:1 supervision with use of

volunteers, sitters, or specialized staff. Other interventions that can be used

include special color-coding for the residents clothes, use of alarms on bed

and chairs, and tagging system alarms.

A psychiatric care book reference addressing elopement risk explains the

importance of knowing which patients have an increased risk to elope and

being aware of their location when door exits are opened. This reference also

explains the importance of increasing supervision for patients at high risk for

elopement by checking on them at least every 15 minutes.

A 2010 study by Gonzales and Valente found that wandering and elopement

issues that occurred at the Los Angeles Veterans Administration (VA) facility

did not have an adequate response plan to find missing patients. After a

number of incidents were reviewed and analyzed, they concluded that the first

major flaw in their attempts to locate a missing patient included the lack of

using search grids while searching a unit. Search grids can facilitate a

deliberate and coordinated effort once staff has been educated on how to use

them to find a missing patient. Next, they identified the need for better

communication and directions. Educational programs and mock drills including

the use of sample grids improved their communication with each other during

the search.

The Oxford Dictionary defines an ombudsman as “an official appointed to

investigate individuals' complaints against maladministration, especially that

of public authorities.”

In the United States, it is required for each state to have a long-term care

ombudsman appointed. Ombudsman programs and the specific duties of a

state’s ombudsman vary from one state to another. In West Virginia, some of

the responsibilities of the ombudsman role include providing outreach services

to residents; identifying, investigating, and resolving complaints made by long-

term care residents; coordinating efforts with other agencies for long-term

care; arriving for routine and unannounced visits to long-term care facilities;

and promoting community awareness about long-term care issues. Types of

concerns that are addressed by an ombudsman may include quality of care

issues for long-term care residents, billing issues, and appeals for facility

transfer/discharge. Other situations that an ombudsman can address include

incompatible roommate complaints in a nursing home facility, nutrition

concerns, privacy issues, or suspected abuse/neglect. Any type of concern that

a long-term resident has can be addressed by the ombudsman.

When it has been identified that a resident is missing from a long-term care

facility, the direct care provider should prepare to conduct a “hasty search.”

This initial search of the facility should take no more than 30 minutes to

conduct. The search coordinator will assign staff members to different

locations so that the entire facility is explored quickly. It is important to

report back to the search coordinator about the results of the search. Next an

expanded search that includes other facility employees such as security and

environmental services personnel will take place for a few hours. Finally law

enforcement should be called to search the surrounding area of the facility

and the community. Once the law enforcement agency is contacted they take

charge of coordinating the search.

There are numerous types of equipment available to monitor residents in long-

term care facilities to prevent elopement. One type of surveillance technology

includes environmental sensors. Environmental sensors include motion

detectors, which can be used everywhere including the resident’s room.

Video monitoring can be performed by having a camera in the hallway or a

resident’s room connected to a monitor at the nurse’s station. Acoustic

sensors can be placed into each resident’s room to transmit sounds or signals

to a computer or DECT phone. DECT phones help to enhance direct care staff

communication. Tagging systems include use of electronic bracelets. The

facility’s automatic doors can be programmed to respond when the tagging

bracelet moves beyond the public area. Tracking systems that utilize GPS

technology tags can be sewn into the resident’s clothing and then linked to a

staff computer. Automatic doors are another safety feature that can be used.

These doors can have an access code known only to the staff and those who

come routinely for visits.

Technology methods used for assisted rapid response programs include the use

of radio signals and tracking devices. The cost of these services are usually

paid out-of-pocket since insurance companies don’t routinely cover this

intervention. It is also recommended that law enforcement agencies provide

education about prevention of elopement and resources for the facility and

local community of the residents. This can include information about how

people with dementia get lost, ways to identify who they are, and how to

interact with a person who has dementia when they find them lost in the

community.

The Alzheimer’s Foundation of America provides numerous strategies that can

be used for finding and identifying residents who have become lost or are

missing. Residents at high risk for elopement should have a number of

different forms of identification. Examples are identification bracelets and

clothing labels. It is helpful if the bracelets include the individual’s name and

contact information for emergencies. An identification system works well

when it can only be removed by a staff member. The emergency call number

may or may not be connected to a central registry, but a registry program can

help to make this process quicker.

To help find a missing resident as quickly as possible, The Alzheimer’s

Foundation of America recommends to seek help from the general public. One

way to do this is through the Silver Alert program. Silver Alert was modeled

after the Ambler Alert system which was developed to help find children who

are missing. These systems use “Robo-calling” to alert the community to look

for someone who is missing. A number of various media sources are used to

disseminate the information about the Silver Alert situation. These technology

sources include: digital billboard signs, television, and communication systems

that get information out in mass notification with automation systems. These

systems send-out notifications by many ways which include cell phones, SMS

text, emails, and fax. One type of emergency notification system is REVERSE

911®. This system combines mapping and database technology to notify

people who live in specific geographic areas when an emergency situation such

as a Silver Alert arises. This helps to quickly alert the surrounding public of the

situation so that they can assist in locating the missing resident.

Review your facility’s protocol for procedures to handle a resolved elopement.

Resolution procedures should include performing an assessment of the resident

for his/her status after being located in an elopement situation. Next,

examine the resident to determine if any injuries are present. Take the

appropriate measures if injuries are found. Check the resident to make sure

they do not have any objects with them that can cause injury to themselves or

to someone else. If found, remove the object to prevent harm. Reassure the

resident that they need to continue having care in the facility. Staff should

document details of all interventions and procedures performed throughout

the elopement incident.

Let’s review:

Prevent elopement by monitoring residents every day. Use search grids keep

track of resident locations especially during mealtimes and shift changes.

When family members or visitors take residents out of the facility, make sure

that there is a sign-in and sign-out sheet completed Have recent photographs

of the resident in case of a lost situation.

Find out if your facility has an elopement emergency procedure. Become

familiar with the procedures that must be followed. Have the local law

enforcement agency and the residents’ family phone numbers in a file easy to

retrieve to be able to contact quickly when an elopement situation occurs.

Document in the resident’s medical record information about the elopement

and the specific strategies that were used to help find the resident.

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