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The Problem of Elopement in Assisted Living Facilities

The Washington Post recently reported on what is a growing problem here in the United States – elopement from senior assisted living facilities. Elopement in an assisted living facility is when a patient leaves the facility without authorization or supervision. Elopement can be intentional or unintentional, and it can have serious consequences for patients, including death or injury.

According to the Washington Post, “Since 2018, more than 2,000 people have wandered away from assisted-living and dementia-care units or been left unattended outside.” Over 100 have died, although they note that the exact number is unknown because “no one is counting.” More than 61% died after exposure to extreme heat or cold.

At Plattner Verderame, we have seen this problem firsthand. We had the privilege of representing the family of a man who eloped from a nursing facility, was left unattended for hours, and suffered a horrible death in the extreme heat of an Arizona summer.  Under Arizona law, we were able to get a measure of justice for them.

What is elopement?

Elopement in the context of assisted living refers to the situation where a resident leaves the facility without proper authorization or supervision. This term is often used in the context of individuals who may have cognitive impairments, such as those with Alzheimer’s disease or dementia, and may be at risk of wandering away from the assisted living facility.

Elopement poses serious safety concerns as individuals who wander away may become disoriented, lost, or face other dangers outside the facility. Assisted living facilities are designed to provide a secure and supportive environment for residents, and elopement incidents can compromise the well-being of the individuals involved.

To prevent elopement, assisted living facilities are to implement security measures such as secured exits, alarms, and monitoring systems. Additionally, staff members should receive training on how to manage and respond to residents who are at risk of wandering. It’s important for assisted living facilities to have protocols in place to address elopement risks and ensure the safety of their residents.

Failure to respond

In many of the cases studied by the Post, staff members have failed in their duty to residents:

But state inspectors reviewing walkaway deaths have repeatedly found failures by administrators and front-line caregivers. In case after case examined by The Post, inspectors cited evidence of too few people on duty to care for the number of residents, of staff ignoring alarms, of skipped bed checks and staff sleeping on the job, of general neglect and, in a few cases, falsified records.

These “elopements,” the industry term for when a resident leaves unnoticed and unsupervised, were repeated events at even some of the most luxurious facilities and continued to happen even after residents died or suffered catastrophic injuries.

Some families were not even told the truth about what happened to their loved ones. For example, Hazel Place, age 86, was ignored for six hours in sweltering Colorado heat after wandering into a courtyard in 2021. Her family was told she “passed outside watching the sun set, an activity that she loved.”

Lack of oversight

There is also an appalling lack of oversight when it comes to reporting these incidents. Per the Post,

Most states require facilities to report missing residents and preventable deaths, according to a Post review of records and state regulations. But regulators have cited facilities more than 200 times since 2018 for failing to properly report missing residents — that’s 1 in 10 of the walkaways identified by The Post.

Fines seldom exceed $10,000, which is typically about two months’ rent in an assisted living facility. For example, when Ina Rose Jenkins, age 88, wandered away and died in 104-degree heat in Arizona, the state fined the Silver Creek Inn the “most it could,” which was only $500. In Connecticut, South Dakota, and Wyoming, the state has no power to fine at all.

“Any incidents where a resident was injured or worse are truly tragic, and we encourage assisted-living communities to have policies and procedures in place to help prevent and address these rare occasions,” says LaShuan Bethea, executive director of the National Center for Assisted Living. “If staff do not adhere to those policies and procedures, they should be held accountable.”

How can assisted living facilities prevent elopement?

Assisted living facilities should employ various strategies and protocols to prevent elopement and ensure the safety of residents, particularly those with cognitive impairments such as Alzheimer’s disease or dementia. Here are some common measures:

  • Secure exits
    • Facilities should have secured exits and entrances with keypads, keycards, or other access control systems.
    • Alarms may be installed on doors to alert staff if they are opened without authorization.
  • Wandering prevention technology
    • Facilities can use electronic monitoring systems, such as wearable devices or electronic bracelets, to track the movement of residents and alert staff if they approach a restricted area.
    • Motion sensors and other technology can be employed to detect movement in certain areas and trigger alarms.
  • Staff training
    • Staff members should be trained to recognize signs of restlessness, agitation, or other behaviors that may precede elopement.
    • Training may include techniques for de-escalating situations and redirecting residents to prevent wandering.
  • Structured activities
    • Engaging residents in structured and purposeful activities can help reduce restlessness and the likelihood of wandering.
    • Scheduled routines and activities can provide a sense of familiarity and security for residents.
  • Physical environment design
    • Facilities should be designed with clear pathways and visual cues to help residents navigate without becoming disoriented.
    • Color-coded or easily distinguishable hallways and common areas can aid in finding ways around the facility.
  • Care plans
    • Individualized care plans should be developed for residents, taking into account their specific needs and risks.
    • Regular assessments should be conducted to update care plans as residents’ conditions change.
  • Supervision and monitoring
    • Increased supervision, especially during periods of increased risk, must be implemented to ensure that residents are safely monitored.
    • Regular checks on residents, especially during the evening or night, can help prevent elopement.
  • Family and caregiver communication
    • Regular communication with families and caregivers can provide valuable insights into a resident’s behavior and any changes that may indicate an increased risk of elopement.

At Plattner Verderame, PC, our nursing home abuse and neglect attorneys understand how to hold nursing homes and assisted living facilities accountable when a resident wanders away and suffers injuries or a tragic death. If your loved one experienced a nursing home injury, call our offices today or contact us online for a confidential discussion of your case. We serve clients out of our Phoenix and Tempe offices.