Edition: March 2008 - Vol 16 Number 03
Author: Laura Thill
Try as they may to offer compassionate care to their residents, and ensure their safety and security, long-term-care providers tread a fine line between creating the least restrictive environment possible and preventing elopement. Regardless of their diligence and efforts to prevent residents from leaving the premise, every so often, elopement incidents do occur, placing the missing resident at risk for injury, exposure or death, and leaving the nursing home vulnerable to citations, legal issues, hefty fines and even potential closings.
Elopement occurs when a resident leaves the nursing home without authorization or appropriate supervision, according to federal regulations cited by Bruce Yarwood, president and CEO, American Health Care Association (Washington, D.C.). The individual’s departure is very purposeful. In his or her confused state, the resident may believe he has to return to work or get home to feed a pet, adds Brad Klitsch, vice president of market development, Direct Supply Healthcare Equipment (Milwaukee, Wis.).
“Because of the potential danger to a patient’s safety and well-being, elopement is a serious concern for providers and regulators alike,” says Yarwood. “In fact, breeches to patient safety determined to be elopement can result in The Centers for Medicare and Medicaid Services (CMS) finding of immediate jeopardy, along with significant civil monetary penalties or other CMS-imposed remedies.”
Who is at risk?
There is no single patient profile considered at high risk for elopement, according to Yarwood. “Certainly, individuals with cognitive impairment, such as those suffering from dementia, Alzheimer’s disease or any number of psychiatric diagnoses may be more likely to wander,” he explains. “Even so, an individual’s age, mobility and other factors must be considered when assessing an individual’s overall risk for elopement.” So, a resident with Alzheimer’s disease who is mobile is at greater risk for elopement than he or she would be when recovering from hip replacement surgery, he adds.
About 50 percent of all nursing home residents suffer from some level of dementia, according to Klitsch. “Wandering is most often associated with dementia,” he says. In fact, between 11 and 24 percent of all residents with Alzheimer’s disease are known wanderers, he points out. Whereas wandering suggests aimless pacing throughout the nursing facility, “a lot of wandering incidents include elopement,” he says. “So, essentially half of nursing home residents could be considered at risk for elopement.” Still, many incidents are unreported, he notes.
Just as there is no single patient profile associated with the risk for elopement, so, too, is there no typical profile of a nursing home where the risk is greater, according to Yarwood. “Still, a facility dealing with significant staff turnover would need to make certain that new staff are educated about patients who tend to wander [as well as] safety measures the facility employs to prevent unsafe wandering and [its] policies and procedures regarding elopement,” he says. “Many facilities now include special care or memory care units designed to address these [residents’] unique needs.”
Preventing elopement really should begin with the admissions process to a nursing home, explains Yarwood. Residents and facilities should be appropriately matched, such that a particular nursing home can meet the needs of each resident it admits. “Next, an individual care plan must be developed to address those needs, [based on] whether or not the patient has a history of unsafe wandering or elopement,” he says. “The ideal care plan is resident-specific and adapts to any changes in a resident’s condition that would impact the care plan.” To ensure that it meets a resident’s changing needs, the plan must be continually evaluated.
Products and technology
Today, long-term-care providers must employ the least restrictive means possible to ensure resident safety and security. “Patient protections have been enacted that limit the use of physical or chemical restraints or confinement without appropriate consent,” says Yarwood.
There is a wide array of wireless, electronic technology available to monitor residents at high risk for elopement in nursing homes. For example, wristwatch transmitters worn by patients are designed to continuously send silent signals through a wireless network to a base unit, which alerts caregivers when residents leave or enter a restricted area, approach certain exits or even remove the device (e.g. some devices measure skin temperature). Some transmitters and monitoring devices send audible or visual alerts to staff, or activate magnetic locks on doors. In addition to wristwatch transmitters, manufacturers offer pendants, wristbands and ankle bands as well. Systems range in sophistication from stand-alones with a local alarm to monitor one door, to networked systems that monitor multiple doors and areas.
“Facilities should be certain that use of such monitoring systems align with patient choice and the family’s preferences,” says Yarwood. “Also, facilities must incorporate routine testing of these systems, which may require that alert devices be replaced on a regular schedule.”
When elopement occurs
A facility’s procedures for responding to elopement may be outlined in its disaster and emergency preparedness plan, according to Yarwood. “Typically, any facility staff who suspect a patient or resident is missing, or that elopement has occurred, would notify the administrator or director of nursing,” he says. They, in turn, “would initiate a head count to verify that the resident is absent and might have wandered off. Staff also would search the facility [to determine] if the resident simply wandered into a wrong room, and sweep the grounds outside of the building in search of the missing individual.”
If the administrator, director of nursing and staff cannot locate the missing resident, and elopement seems likely, the nursing home notifies family members, local police authorities and perhaps the media, he continues. In addition, key staff members thoroughly review the missing resident’s chart to identify past habits, or clues indicating where the agitated or confused individual may have gone. “Having specifics about the individual’s background and habits can help a facility better deploy resources and ensure [his or her] speedy and safe return,” he adds.
When a resident elopes, the likelihood of injury or death increases after 24 hours, says Klitsch. “So, it is important for everyone to act immediately,” he explains. “And, [staff and police] must recheck areas where the missing individual might be likely to go.”
The cost of elopement
The injury or death of a missing resident is, by far, the worst scenario a nursing home faces. However, the legal implications are dismal as well. “The cost of litigation [following an elopement] can be as high as $300,000 if the missing individual has been hurt,” says Klitsch. This generally includes the price of the facility’s lawyer, plus the nominal award to the resident’s family. “If the [resident dies], and death could have been prevented, the legal costs may be even higher,” he adds. In these cases, awards easily can be as much as $1 million.
Nursing home administrators and directors of nursing face the daily challenge of ensuring their residents are safe and secure. Distributor reps can help their long-term-care customers meet this challenge by educating them on new technologies that best fit each facility’s culture, and explaining how these products have helped other facilities prevent elopement from occurring.