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Reexamine elopement risk assessments

October 19, 2015
by Carl Bloomfield, AAI; and Bette McNee, RN, NHA
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An estimated 30 percent of nursing home residents and between 25 percent and 70 percent of community-dwelling older adults with dementia wander from their supervised healthcare settings at least once during their stay. Incidences of elopement have resulted in costly liability claims. One major insurance carrier reported an award more than $500,000 for a single elopement claim in 2012. Healthcare providers have been cited and fined by regulators and litigated out of business as a result of elopement incidents.

Providers implement countless interventions to mitigate the risk of elopement, ranging from painting murals on exit doors to building never-ending walking paths to buying bracelets for residents to wear that lock nearby doors and sound alarms. Although elopement prevention plans often include a variety of best practices, a provider’s approach could be significantly improved by having a comprehensive risk assessment program to identify residents who wander.

Providers regularly use standard risk assessment tools, but many tools don’t identify key risk factors. You can tell if your elopement risk assessment program is missing the mark and could be working harder for your facility by asking yourself the following five questions.

1. Are you taking "no previous episodes" at face value? Most elopement risk assessments ask about a resident’s previous history of elopement, wandering or “getting lost.” Since a resident who had previously lived alone may not share past episodes of getting lost, or residents who lived with caregivers may not recognize “wandering” as roaming in familiar settings, the response of “no previous episodes” will not accurately reflect the resident’s current risk for wandering behaviors. Improve standard assessment tools with the inclusion of probing interview questions such as: “Have you ever found yourself in a room and were unsure how you got there?” “Has Mom ever wandered away in a store while you were shopping?” “Does Dad roam about the house without completing a task?” These types of questions will help residents and their families respond more accurately about behaviors that put one at risk for wandering away from a supervised healthcare setting.

2. Do you have a real sense for activity patterns? Another risk factor that is often missed during an assessment is that of previous activity patterns. Activities that are often discouraged in a supervised healthcare setting—such as smoking or having an alcoholic beverage—are often not reported, but these behaviors do put a resident at an increased risk for elopement. The staff member responsible for performing a risk assessment needs to establish a rapport to elicit an accurate history. Another activity pattern that will put a resident at risk for elopement is the concern for or the absence of a pet, wildlife or even a garden. Residents who perceive themselves to be caretakers are at increased risk for elopement because of their desire to return to their obligations of caring for a pet, feeding birds or squirrels or even picking vegetables from the garden. Even if pet care is provided during the resident’s stay in the healthcare setting, the risk of elopement still exists.

3. Is a red flag raised for residents who exhibit confusion? Since a resident’s cognitive status is also a key risk factor, standard elopement risk assessments delve into a resident’s diagnosis of dementia and memory changes. Residents who have not been diagnosed with dementia may not trigger the risk factor; however, they still may be at risk for wandering and elopement because of confusion, which can be a side effect of new medication or from a change in setting, routine or sleep pattern. While assessment tools can be updated to include these factors, more important is the regular observation and supervision of newly admitted residents. Episodes of wandering and elopement are likely to occur within the first 48 to 72 hours from move-in and are usually related to changes in setting, routine and sleep pattern. The Alzheimer’s Association estimates that nearly half of all elopements occur within the first days after admission. They recommend observation and supervision by moving new residents to rooms away from exits and closer to community areas.

4. Are you listening closely to residents’ complaints? A resident who often says, “I want to go home” or “I need to get to work” may be assessed as being at risk for elopement. However, a short-term rehabilitation resident who expresses frustration with the duration of the rehabilitation stay is at greater risk for elopement despite the lack of verbalizations. A resident’s complaints about complying with plans for length of stay and discharge plans is a risk factor for elopement that may be missed in standard assessments.

5. Do you assume immobile residents are not at risk? Finally, a resident’s inability to independently ambulate can inaccurately reflect a risk for elopement. Surprisingly, residents who require one or two people’s assistance to take just a few steps have mustered the ability to exit the healthcare setting without the knowledge of staff. Residents who can stand—regardless if standing puts them at great risk for falling—should still be assessed for risk of elopement. In addition, residents whose risk was assessed at move-in should be reevaluated often as they progress in their therapy regimen.