Editor’s note: This is the final article in a three-part series on elopement prevention and response in nursing homes. The first article looked at risk assessment and care planning, and the second article addressed staff training, as well as policy and procedure development.
Effective risk management of elopements requires that nursing home leaders address four core areas, says Elizabeth Neidig, a healthcare litigator and partner at Hall Prangle + Schoonveld, LLC in Chicago. These four areas are defined in the following chart:
|Elopement Risk Management Goals |
When a resident elopes, key questions to ask from a risk management perspective include the following:
– Was the resident appropriately identified as an elopement risk?
– Did the facility have interventions in place:
Were those interventions not only identified but implemented?
– Was the resident located quickly and without injury?
– Was the family notified:
With the appropriate demeanor acknowledging the seriousness of the elopement?
With a solutions-oriented approach to work with the family to prevent another elopement?
Source: Elizabeth Neidig, a healthcare litigator and partner at Hall Prangle + Schoonveld, LLC in Chicago.
Taking the following steps can help directors of nursing services (DNSs) and other facility leaders meet these risk management goals:
Know the facility’s security system
Providers should conduct regular preventive maintenance on all alarm systems, says Angie Szumlinski, LNHA, RN-BC, RAC-CT, BS, director of risk management for HealthCap/QA Reader in Ann Arbor, MI. “Even during a pandemic, the facility is responsible for identifying any mechanical failures in the system and addressing them timely because residents are at risk.”
For example, earlier this year, a man with dementia died after eloping from an assisted living facility when the door alarm did not sound, notes Szumlinski. “So, whether maintenance or housekeeping is responsible for doing these checks, they need to be done no matter how busy team members are. Residents change day to day, but the environmental piece is easy to maintain if someone on the management team is monitoring the preventive maintenance schedule.”
Common security system issues to consider include the following:
* “Secure” doors. In most states, nursing homes cannot have an absolute lockdown system, points out Janet Feldkamp, RN, BSN, LNHA, CHC, JD, a partner in the Benesch Healthcare + Practice Group at Benesch, Friedlander, Coplan & Aronoff in Columbus, OH. “So, a secure unit usually is mag-locked (i.e., locked using an electromagnetic device). Either you have to enter a code on a touchpad to leave, or you have to hold down the bar on the door for the required amount of time, usually 15 or 30 seconds. Both types of mag-locks provide opportunities for elopement, so you need to have a routine process to check your doors based on the type of mag-lock you use and ensure that residents can’t adapt to it and get out.”
* Wander management bracelets. Using a wander management bracelet on a resident who is exit-seeking or wandering is not a one-and-done event that ends with putting the bracelet on the resident, says Feldkamp. “For example, many residents don’t want to wear it—they even try to cut off the bracelet. If you decide to put it on their ankle or somewhere on their wheelchair, do you have an order to do that and the consent of the family? Does the bracelet work where you put it, or is it positioned too low to lock down the door timely or send notifications to staff?”
Other issues that need to be considered with wander management bracelets include the following:
- Does the resident need the bracelet for short-term or long-term use?
- How often is it checked (for function, expiration date, etc.)?
- Who checks it?
- Is that review documented?
* Windows. “Windows should be secured in a manner that is allowed by your local fire code and the Life Safety Code,” says Feldkamp. “You don’t want to allow someone to open a window and crawl out—whether their room is on the first floor or a higher floor. Residents don’t always pay attention to what floor they are on. They just go out any unsecured window, which can have devastating consequences.”
Facilities also should secure windows in nonresidential areas, says Feldkamp. “Sometimes, facilities forget to secure windows in the activities room and other group areas. You want to have a plan to secure all windows and to check the windows on a routine basis.”
Remember the human element
“Mechanical devices, including door alarms and bracelet monitoring systems, are useful tools for elopement prevention, but you shouldn’t get too comfortable and depend solely on such devices,” says Szumlinski. “Mechanical devices will warn you—until they don’t. So, no matter how secure your unit or facility is, the best way to be assured that no residents are eloping is to have staff physically there with the residents doing regular checks.”
Be extra careful in these high-risk situations
Common situations where providers may need to adjust monitoring to prevent elopements include the following:
- New admissions. “Providers may want to consider using some type of heightened observation for all new admissions,” says Feldkamp. “Even if your team doesn’t identify a resident as being at high risk for elopement, the disruption to the resident’s life could spur a behavior change that results in elopement.”
- Meal-time. “Dining is a huge risk area because the dining room often is full, people tend to wander in and out, and there may be less supervision on the units during meal-time,” says Szumlinski. “If you have a lot of high-risk residents, you may want to post a staff person outside of the dining room during meals to monitor the doors.”
- Shift change. “With so many staff coming and going at shift change, residents can get confused and think that they need to come and go as well,” says Szumlinski. “In addition, staff sometimes prop open doors when they leave to help other staff get in and out easier. So, shift change is another high-risk time when it would be helpful to have hall monitors checking your doors.”
- Night shifts. “Installing outdoor motion lights that trigger when a resident or anyone else walks out into the courtyard or other open areas at night is a great practice,” says Szumlinski.“That is another tool that you can train night-shift staff to use to get an idea of whether a resident has left the building.”
- Holidays. “Sometimes, another resident’s family member will inadvertently help a resident elope, especially in busy times like holidays,” says Feldkamp. “For example, one Easter weekend prior to the COVID-19 pandemic, a visitor to the facility held the door open for a resident to leave because this resident was extremely well-groomed and well dressed—she even had her purse in her hand. So, your policies and procedures should include a component to mitigate the risk of a visitor-assisted elopement.”
“This is more common than it once was because so many residents look like they belong in the community,” adds Szumlinski. “They are dressed in street clothes and sitting in the common area, and they can get up and walk right out of your building. For example, one resident eloped from a building on New Year’s Eve by walking out unnoticed with a group of visitors.”
- Renovations. When facilities are doing renovations, alarms may be disengaged, or the electricity may even be shut off for a period of time, says Janine Lehman, RN, RAC-CT, CLNC, a clinical nurse consultant with Proactive Medical Review & Consulting in Evansville, IN. “There have been cases of immediate jeopardy elopements that involved construction that interfered with the monitoring systems that facilities had in place,” she explains. “So, you need to know in advance from your contractor any time that this will happen. Your team has to prepare to be on alert and do some type of more frequent in-person monitoring system because you can’t rely on those alarms during that period of time.”
- Fire alarms. “What happens when the fire alarm goes off? All of the doors automatically unlock,” points out Feldkamp. “So, if a resident on your secure unit is standing by the exterior door or even by a door to an unsecured unit when the fire alarm goes off for any reason, even for a fire drill, you face a danger of elopement that your action plan should address. A surprising number of residents who are unsafe to be out alone leave facilities this way.”
Remember key steps when an elopement occurs
Taking the following steps can help providers stay on track from a risk management perspective if a resident elopes:
* Work quickly to implement the facility’s action plan. Residents may elope in the middle of summer when it’s 110 degrees Fahrenheit or when it is 30 below in late January, or there may be train tracks or other dangers nearby,” Neidig points out. “So, you have to be able to quickly identify when residents leave and how to get them back.”
* Keep an elopement timeline.“Timelines are vitally important,” says Feldkamp. “When you have an elopement and your team is working through your elopement process, keeping a timeline of what happens when—how your team implements the elopement policies and procedures—from the moment you identify that a resident has eloped will benefit the facility from a regulatory perspective in the current situation and from a risk management perspective in the future.”
Note: An elopement timeline can help facility leaders complete an investigation using AAPACN’s Investigation Checklist to identify and address concerns through the Quality Assurance and Performance Improvement (QAPI) process.
* When an eloped resident is found, do a full assessment.When a resident is located and does not require emergency services, they still should have full assessment when they return to the facility, notes Lehman. “This should be a thorough head-to-toe assessment, including a medication review.”
In addition to ensuring the resident has no health issues resulting from the elopement, this assessment should look for what caused the elopement, explains Szumlinski. “Especially if the resident’s elopement is outside their norm, you want to do a full assessment to identify whether a medical issue contributed to the elopement. For example, was there a medication change that affected the resident? Or, do they have a urinary tract infection (UTI)? You want to identify any health issues that may cause that resident to try to elope again.”
* Plan elopement and post-elopement notifications thoughtfully. In many elopement cases, providers will need to notify the police if the resident isn’t found either in the building or on the property, says Lehman. “You should call the police, the family, and anyone else who may need to be notified to either help with the search or care for the resident upon their return, such as the resident’s physician. There also must be a follow-up notification process to alert these key parties if the resident returns to the facility.”
Weather may impact notification timing, stresses Feldkamp. “For example, if your investigation identifies that the resident went missing in a nightgown with no socks and shoes when it’s 5 degrees Fahrenheit outside, you may not want to wait until your investigation is fully complete before you alert the police.”
* Learn the art of family notifications. “You must have appropriate—not just timely—communication with the family,” says Neidig. “Consider this scenario: A resident elopes but returns uninjured to the facility 45 minutes later, completely happy and having enjoyed a ride in a police car. If the first thing that you say to the family is, ‘We didn’t even know she was gone,’ you are just asking for a lawsuit. You have to go into the conversation understanding the severity of the situation. Making light of it won’t help you—and it may anger the family.”
Even when the family doesn’t bring a lawsuit related to the elopement, how the facility communicates with the family can tip the scales toward a lawsuit down the line, says Neidig. “For example, if something else happens to the resident two years later, the family in that scenario often will sue and tack on the elopement, still upset about how the resident left and no one knew she had eloped.”
The person in charge of family notifications has to have the appropriate demeanor—demonstrating that they understand that the elopement was an unfortunate occurrence—and be solutions-oriented, says Neidig. “You want to be able to tell the family what interventions were in place, how the resident got out, and what your team is doing to fix that situation so it doesn’t happen again.”
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