Elopement from a long term care facility

elopement from nursing home, Med League, Sara Jean Fisher, eloping from long term careTo the uninformed, elopement is not a case of Mom being spirited off by some geriatric Romeo to “tie the knot” with white gardenias and wedding cake. It is a serious and potentially deadly situation. The definition of elopement used by the American Health Care (AHRQ) is “when a resident’s location is unknown” (1). Here are some examples:

A nursing home sounded the Code Grey alarm for “missing resident” at about 4 PM when a resident could not be found for dinner. No one had remembered seeing the resident since approximately 2 PM. Protocol was followed but the resident could not be found. In the midst of the search, the facility elevator locked between floors and they waited for an elevator mechanic. By 7 PM, staff were hearing a banging sound. Someone said, “It’s coming from the elevator”. The elevator mechanic brought the car to the first floor, opened the door and found the missing resident. She had wandered in on her way to 2 PM bingo, then the elevator locked. She sat down and fell asleep. When she awoke, she was hungry and knocked on the door to get out. She suffered no permanent or serious injury.

One cold morning in February, the security officer at a center city nursing home opened the door for a woman who worked at a nearby newspaper. She had with her one of the male residents of the facility who was wearing the woman’s coat over a hospital-type gown, a diaper, no shoes or socks and a facility bracelet with his name on it. She stated that when she arrived at work that morning, she found him huddled in the corner of the building entryway. When the security guard had let the cook in earlier, he had used the rest room right afterward and left the lobby area unattended. Apparently the lock on the front door had not engaged as the cook entered, and when the resident got off the elevator, he was able to go right out the door to the street. He had wandered across the street and around the corner to the sheltered doorway of the newspaper office where he was found. Although he waited on the doorstep possibly for an hour, he suffered no permanent or serious injury.

Several years ago in January, a woman with dementia and several other health issues was taken to a nursing home by her children because they were unable to care for her any more at home. The new resident was very unhappy there, refused to eat, and frequently yelled that she wanted to go home. Several days after she was admitted, she went missing at bedtime and could not be found. The facility initiated its elopement protocol and exhausted all recovery efforts unsuccessfully. At 10 AM the next morning, the woman’s body was found in the dumpster of a shopping center near the nursing home. She had left the facility with the visitors, wandered to a nearby mall and climbed up boxes to get into the dumpster. She died from exposure to the elements and dehydration.

The elopement of a resident from a long term care facility is one of the ”never events” that nursing homes dread. The term, first coined by Dr. Ken Kizer in 2001, was used when discussing serious medical errors which are clearly identifiable, measurable and preventable, including fall with injury, pressure ulcer, dehydration, constipation and elopement. No facility wants one of its residents to successfully wander or elope from its safe confines, yet all should be prepared with an emergency protocol to initiate should it occur and a prevention policy to reduce the number of occurrences.

Emergency response protocol for elopement usually includes first searching every conceivable space of the unit (behind doors and curtains, under beds, in showers, closets, and cabinets). Then the search extends to the entire building, and then the neighborhood. Generally, administrators and the police are notified. One person is assigned to call all family members/friends the resident may contact and also all local hospitals with a description of resident. It is a good idea to fax a recent picture to hospitals if possible. If the search must extend to the neighborhood, teams are assigned to grids on a map and they should have a picture of the resident and a cell phone to check in every 15 minutes.

There are numerous interventions a facility can implement to prevent resident elopement. Here are some of them:
• Perform elopement assessment on each resident who is new, readmitted, experiences any significant change, and regularly throughout the year, e.g. quarterly.
• Have pictures taken of all residents and a photo of known wanderers/elopers. Place these on each unit and at doors to the outside, and large gathering spaces.
• Don’t place residents at high risk for elopement on the first floor of the building.
• Put wallpaper over doors that matches walls so the door is not obvious as an exit.
• Paint a black circle (hole) on the floor in front of emergency doors to deter crossing.
• Provide planned activities for shift change and close of visiting hours, when a high number of people are moving in and out of doors. The activities will take place in rooms away from the doors.
• Provide some identification label or badge to visitors that must be turned in before they are able to leave the facility.
• During a “Code Grey”, call all elevators down to the first floor and check them.
• Provide supervised moderate exercise for potential elopers to discourage wandering.
• Some facilities have a locked unit for extreme cases.
• Perform visual face to face checks every 15-30 minutes on known elopers when they are agitated.
• Provide regular “drills” like fire drills, to all shifts, to rehearse staff and to sharpen their response time and understanding of emergency procedures. A former president of the American Medical Directors Association shared how he did this. He took a resident into his office and closed the door. Then he waited to see how long it would take for the staff to realize the resident was missing. In some cases, it was hours.
• Alert staff to closely monitor stairway entrances and doors to the outside (including loading docks) during fire drills when alarms may be off. Do a head count after every emergency “drill.”
• Anticipate physical needs (pain management, food, toileting) of dementia residents who are able to move about on their own to deter purposeful wandering.

Here are some resources for further information and statistics on elopement:
(1) http://www.portal.state.pa.us/portal/server.pt/community/hospital/14149/chapter_51_questions_and_answers/558509
(2) https:www.guideone.com/SafeeyResources/SLC/…cs_elopement02 Resident elopement and case study
(3) www.nccdp.org/wandering.htm
(4) www.ncbi.nim.hig.gov/pubmed/15633945

Sarah Jean Fisher MSN, RN-BC, BA is a nursing home expert who performs expert witness reviews for Med League.

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