Improper monitoring of a senior living resident with dementia leads to elopement and injury
An 85-year-old woman with moderate dementia lived in a senior living memory care wing for three years. She had a history of wandering in and out of other people’s rooms and a history of falling. One afternoon, the woman was found lying on the ground on the driveway outside of her building. Her face was bloody, and she was confused with no memory of her circumstances. She was transported to the local hospital by ambulance with apparent facial and bilateral arm injuries. The emergency department (ED) physician diagnosed her with acute left intraventricular hemorrhage, acute complex left zygomaticomaxillary facial fracture, a right distal radius fracture and a left distal humerus fracture.
The ED physician transferred her to a tertiary hospital for treatment. An orthopedist treated her arm fractures conservatively, and one week later, an ENT specialist performed surgery to repair her facial fracture. She was hospitalized for two weeks and was discharged to a different senior living community. The family filed a malpractice claim against the senior living community, alleging failure to ensure safety from elopement. The claim was settled with a payment to the family on behalf of the senior living community.
The investigation revealed that on the morning of the 85-year-old woman’s elopement and subsequent fall, the senior living community conducted a scheduled fire drill. As was their usual practice, the maintenance team turned off all exit door alarms. Following completion of a fire drill, their usual practice was to turn off the fire alarms and re-arm all exit doors. However, on this afternoon, a nurse who was new to the community turned off the fire alarm in the memory care wing because the noise was upsetting the residents. In turning off the fire alarm, the nurse did not realize she still needed to re-engage the door locks and door alarms, leaving residents vulnerable to elopement with no warning alarm. The 85-year-old woman left the memory care wing through the unlocked door without tripping the door alarm, and she wandered outside the building and fell. Her care team did not know she had left the wing or the building until being notified that she had been found injured outside.
The experts who reviewed the claim criticized the senior living community for failing to inspect and assess all secured exits following the fire drill, and for failing to educate the memory care team about elopement risks and the prevention plan, including how to safely engage door locks and alarms.
Failure to ensure safety from hazardous wandering and elopement
Hazardous wandering and elopement can put a person with cognitive and/or mobility issues at risk for injury, and lead to regulatory fines and malpractice claims for senior living and other health care organizations.
Monica Chadwick, Senior Risk Consultant, Constellation
The Alzheimer’s Association estimates 1 in 6 persons with dementia wanders, and that anyone with memory or cognitive problems who is mobile is at risk for injury due to unsafe wandering.1
Elopement is generally defined as when a person with cognitive or memory problems leaves an area meant to keep them safe. Elopement may happen so infrequently that senior living communities and hospitals may not have protocols to reduce the risk of unsafe leaving, or drills to respond to elopement situations. The use of door locks and alarms may give care teams a false sense of security; however, as this case illustrates, alarm technology is only as good as the human interface.
Fully secured buildings, including those that utilize delayed egress locking arrangements, sometimes experience conditions when those security provisions are compromised. For example, doors that are normally locked in a secure unit will disengage during a power outage or fire alarm activation, as required by Life Safety regulations. These are the times that the built environment, which was designed to help prevent elopements, is most vulnerable as the building is no longer physically secured by mechanical and electrical equipment. Care teams must be trained to recognize these vulnerable periods when the building is not fully secured.
Stanley Szpytek, Jr., President, Fire and Life Safety, Inc.
Ten strategies to reduce the risk of elopement-related harm
- Complete a risk assessment for cognition, wandering/elopement risk and mobility on admission, routinely and after a change in condition.
- Implement a care plan with targeted, patient-centered interventions for at-risk persons. Monitor the care plan’s effectiveness and modify it as needed to minimize the likelihood of elopement.
- Use team communication processes and tools, including at-risk person identification.
- Communicate with an at-risk person’s family about the benefits of mobility versus the risk of unsafe wandering using a shared decision-making model.
- Utilize a sign-in/sign-out log system.
- Develop an elopement/unsafe leaving/missing person response plan and checklist.
- Perform elopement/unsafe leaving/missing person drills.
- Use exit alarm technology; routinely test and inspect the system using a checklist to ensure locks and wander alarms are properly reset after a condition occurs, such as a fire alarm system activation or a power failure that disengages critical safety features.
- Train the entire care team on life safety systems, including locking provisions, so they know how these systems disengage and can leave at-risk persons vulnerable to unsafe wandering and elopement.
- Maintain external facility grounds in a safe manner and conduct routine safety rounds.
Watch our on-demand webinar, Preventing Injury Due to Unsafe Wandering and Elopement, to learn more about reducing the risk of injury due to elopement.
1Alzheimer’s Association. Wandering. https://www.alz.org/help-support/caregiving/stages-behaviors/wandering. Accessed May 18, 2023.
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