Nursing home and assisted living elopement highlights a provider’s duty to adequately protect those residents who suffer from cognitive deficits that result in poor safety awareness.
Protecting Residents
After an elopement occurs, the immediate result is the frenzy of the search as well as various notifications, including of law enforcement, family members, the media, regulatory agencies, and the resident’s physician. But ultimately the onus will be on the facility to demonstrate whether adequate measures were instituted to protect the resident.
Defending the care of a resident with documented cognitive impairment who elopes is challenging at best. A mere glance outside the front door of most long term care facilities brings to mind the frightening dangers that await a confused resident: extremes in temperature, bodies of water, busy thoroughfares, train tracks, expansive woods, uneven terrain, and wild animals. The consequences to the resident can be devastating.
On the less-distressing end of the spectrum is a dementia resident with the anxiety of being lost; on the other end is the tragic—and often avoidable—loss of life.
Although a facility’s responsibility to protect a resident from harm is clear, a screening assessment for elopement risk is often absent from the admission process. Because elopements generally occur in low volumes, the importance of this risk assessment is often overlooked, and even when facilities have an elopement screening tool available, the assessment is often conducted after staff observe that a resident is displaying wandering tendencies or has unsuccessfully attempted to elope.
However, many elopements occur in the first few days after admission as the resident transitions to a new environment, and many occur as a consequence of a first wandering episode. As such, a reactionary, post-elopement assessment leaves those who are in most need of protection without any safeguards.
Elopement Defined
Wandering refers to a resident with cognitive impairments moving aimlessly about inside a facility, without an appreciation of personal safety needs, while elopement is when a resident leaves a safe area unsupervised and unnoticed and enters into harm’s way.
Residents who elope are differentiated from wanderers because they make purposeful, overt, and often repeated attempts to leave the nursing home and its premises.
While wandering in a facility can present harmful situations for a resident if adequate protections are not in place, such as preventing resident access to chemicals and stairwells, the opportunities for injury multiply after a resident elopes from the nursing facility.
Elopements remain among the most costly risk exposures in the long term care setting. According to CNA’s “Reducing Risk in a Changing Industry: CNA HealthPro Aging Services Claims Analysis 2004–2008,” the average paid claim for an alleged elopement in the for-profit skilled nursing setting was more than $325,000.
According to the Briggs Corp., 10 percent of nursing home lawsuits deal with elopement, and 70 percent of these suits involve the death of a resident. In 45 percent of these cases, the elopement occurred within the first 48 hours of admission.
When a resident has an impaired ability to make rational choices that will reasonably ensure his or her safety, the responsibility is on the facility to demonstrate that 1.) staff assessed the resident’s risk to elope; and 2.) staff implemented measures to protect the resident when that resident was no longer able to make sound decisions.
It is nearly impossible to defend a process that leaves the responsibility for the safety of a vulnerable adult with that person. It is also difficult to defend a facility that admits residents whose needs it cannot manage, and yet neglects to perform an assessment that evaluates for these needs. Further, federal regulations prohibit the facility from admitting or retaining residents it cannot protect.
Admissions Should Follow Assessment
A facility should base its admission criteria on its ability to protect residents, given the security systems in place, and elopement assessment findings must demonstrate that a resident’s level of risk is commensurate with the facility’s elopement-prevention strategies.
Because an elopement risk assessment is used to determine if a resident has the safety awareness to remain in the facility, an objective, score-based risk assessment should include a defined parameter that indicates an increased risk for elopement and prompts the implementation of prevention strategies (
see Elopement Prevention).
Because many residents in long term care have one or more conditions that compromise their decision-making ability, it is imperative that all residents be assessed on admission and at least quarterly thereafter. Further, if a facility’s admission criteria state that residents who are at risk for elopement are not admitted, the only method of demonstrating compliance with these criteria is by utilizing the admission risk assessment, which should clearly indicate the resident does not exhibit risk factors.
A proactive risk assessment should be an adjunct to the resident and family orientation process. Families should be educated about admission and discharge criteria as well as the facility’s process for managing elopement risk.
If the facility is equipped to care for residents who are at risk for elopement, the assessment should serve as a launching pad for a discussion about setting realistic expectations and the aging process. If the facility is not adequately equipped for this type of resident, the family should be informed that transfer to a suitable facility may be necessary.
Reassessment Required
An additional risk assessment should be performed after there is any change in a resident’s condition. Although a resident may be admitted with adequate safety judgment and awareness, an alteration in cognition may occur subsequent to a change in condition. This could trigger risk factors that were not present on admission.
Dimensions of the reassessment should include physical, psychological, and historical factors, as well as medications. Physical factors include any alteration in cognitive impairment; this is most commonly related to such conditions as Alzheimer’s disease and other dementias. Even mild cognitive impairment can weaken a resident’s ability to make sound decisions. A resident’s mobility and ability to communicate should be included in the reassessment.
Contributing Symptoms
Psychiatric diagnoses, such as delusions, hallucinations, and schizophrenia, also place residents at high risk for elopement. Depression is known to mimic symptoms associated with dementia, and akathisia (motor restlessness characterized by pacing, standing and sitting, or rocking back and forth) may be caused by psychotropic and antidepressant medications.
Medications that cause confusion and restlessness also contribute to elopement risk, while some medical conditions and their associated treatments can aggravate cognitive impairment.
A resident’s history is of paramount importance in the assessment process. It should not only include prior attempts, wandering behaviors, and exit-seeking episodes, but also vocalized statements about wanting to leave the facility.
Residents who are at risk for elopement often have a perceived need to go somewhere or attend to some activity that may once have been part of their daily routine, such as visiting a family member who is now deceased or caring for a pet they once had. These statements, urges, and activities should be recognized and addressed.
Families often inaccurately portray a resident’s history regarding wandering and elopement because of fears about obtaining placement. Problems with definitions of “wandering” further cloud the responsible party’s ability to provide this essential information. Families who understand that objective criteria will be used to substantiate appropriate placement may be more forthcoming with their concerns.
Watch For Danger Signals
Other factors that signal concern include finding a resident “lost” in the facility after admission. An unwilling admission or problem with adjustment to the facility, such as stating a desire to go home, or feeling confined, tricked, or imprisoned, contribute to an increased risk for elopement. Interference with prevention strategies, such as an expressed displeasure with a wandering-prevention bracelet or attempts to remove it, is also a warning sign.
Additional behaviors that could precipitate elopement include those in which the resident is not easily redirected or managed. Some specific wandering behaviors may forewarn of an elopement, including shadowing staff or other residents; self-stimulatory behaviors, due to boredom; and exit-seeking behaviors, such as hovering near exits or waiting for the opportunity to leave with someone.
In the end, all admission documents should serve as a basis for developing an individualized care plan, delineating the family and facility’s role in resident care, and documenting the corresponding safety measures the facility has put into place.
Karen Struck, RN, MS, CPHQ, CPHRM, is a risk management professional, speaker, author, film writer, and independent consultant contracted with Pendulum. She can be reached at struckdown@aol.com or (805) 797-5840.
References
■ Algaier, Ted, “How Communication Technology Reduces Risk: Communications Update,” Nursing Homes, September 2002
■ Turnbull, Gwen, “Feature: The Bottom Line on Wandering and Elopement,” Extended Care Product News 2002 83(5): 20-21
■ Boltz, Marie, “Wandering and Elopement.” Assisted Living Consult, September/October 2006
■ Boltz, Marie, “Wandering and Elopement: Litigation Issues,” The John A. Hartford Foundation Institute for Geriatric Nursing; NYU College of Nursing
■ Federal Regulations 42 CFR Part 483, Centers for Medicare & Medicaid Services website, http://cms.hhs.gov
■ Futrell, M., and Melillo, K.D., “Evidence-Based Protocol: Wandering,” Iowa City, Iowa: The University of Iowa Gerontological Nursing Interventions Research Center. 6 M. Titler, ed., March 2002
■ “National Institute on Aging Progress Report on Alzheimer’s Disease,” Washington, D.C.: U.S. Department of Health and Human Services, Public Health Services, National Institute of Health NIH Publication No. 99-3636. (1998)
■ “Resident Elopement: Facts, Prevention, Responding, Tools and References,” Briggs Corp. Downloaded from the Internet January 2008. www.guideone.com/SafetyResources/SLC/Docs/elopementbrochure.pdf
■ “Transforming Aging Services,” CNA HealthPro Long Term Care Claims Study 2001–2006. CNA 2007