Nursing Home Eloping

From time to time, many of the nursing homes across the country must contend with residents who try to or are successful in escaping.  Within the nursing home industry, this dreaded activity is known as elopement.  American Healthcare (AHRQ) defines elopement as: when a resident’s location is unknown.

Thankfully, most of those residents who do, are found, caught, and returned safely to their facility.  Alarms, procedures and protocols are reviewed extensively to insure that such an event will not occur again.  Elopement is a BIG DEAL with nursing homes and can cost nurses, licensed vocation nurses, certified nursing assistants's and administrators their jobs and livelihood as well as lead to loss of certification and licenses from state authorities.

Sadly, on some occasions, an escape event leads to either serious injury or even the death of a resident. These are the kinds of situations that incur the sensational media headlines, lawsuits and recriminations amongst the parties.

A case in point recently was reported in the March 25th 2014 issue of the Sacramento Bee by reporter Cathy Locke. The Sky Park Gardens, an assisted living facility, was the scene of an escape by a 70 year old man suffering from dementia. He was last seen leaving the facility on March 18th,  On the bright side, this elderly gentleman was then found the following day, March 19th at an out of the area medical facility.  Two similar incidents such as this occurred in 2012 which has caused the State of California to initiate a possible State License Revocation proceeding against Sky Park Gardens according to the Sacramento Bee article.

On one occasion, my wife and I went to visit a nursing home and as we were about to leave through the main lobby entrance/exit, we came upon a scene of chaos.  A wheelchair bound resident had succeeded in making it all the way through both sets of motion sensor activated lobby doors with alarms, rolled onto the sidewalk and tumbled off the curb and down to the blacktop.  EMT’s were called and the elderly gentleman suffered head trauma and facial lacerations as a result.  This resident had never made an impulsive move for the exit doors like this before and caught everyone by surprise.

My own mother, Beatrice, in 2010, pulled off one of her own elopements from a local Sacramento nursing home.  She went missing after breakfast in her room and was gone for less than a couple of hours.  By the time I arrived at the facility after they had alerted me by phone, Mom had already been caught approximately six blocks away from the facility.  A concerned residential citizen, recognizing the facilities’ gown design, called in to report a lost resident (mom) perched under a shade tree with a broken branch (read switch) in her hand for protection.  Mom used the switch to hold the certified nursing assistant's at bay until a local police cruiser arrived to help persuade mom to give up her standoff and return to the nursing home peacefully.  The incident surprised both us as a family and the nursing home staff as to just how ambulatory mom could compel herself to be in an agitated  or combative state.

Thereafter, mom received a souped up alarm unit that remained with her whether 24 hours a day.  Extra certified nursing assistant's and staff were assigned to keep a diligent watch over her from that point on.  When necessary, mom was also placed under close watch right next to the nursing station in her wheel chair. 

In my own opinion, escapes occur for two primary reasons:

Not identifying the flight risk level of a resident

The first one is due to a failure of the nursing facility staff to really get to know and understand the psychology and propensities of each of those residents “most at risk” for flight.  This concern  is born out in much of the on-line literature available addressing nursing home risks.  This was the shared shortcoming between our family and the nursing home staff early in mother’s residency there.

Inadequate staffing levels

The second reason is simply one of understaffing. Not enough personnel to handle and keep an eye properly on all of the residents they are left to cover on their work shifts.  This is particularly true for graveyard shifts between 10:00 pm and 6:00 am.  The presumption behind the lowest ratio of staff to residents during graveyard hours is that vast majority of elderly residents will all be peacefully at sleep.  However, bathroom visits during the night still occur along with soiled bedding, gowns and diapers due to accidents or incontinence.  Add to this, “Sundowner’s Syndrome” that occurs with Alzheimer’s dementia patients and you can have a substantial amount of night time patient/resident activity demanding more from what few staff are on duty than they can adequately deliver.  Staffing at a nursing home can be at the ratio of one for every five residents during the day but then be reduced down to a one for every twenty or more overnight. 

Lets say that your facilities’ overnight goal for a CNA is to check in and attend to each of your twenty residents at least once every hour.  That allows you ,approximately, 3 minutes for each resident check per hour? And this does not allow for the walking time through the halls, wings and corridors that each CNA must cover.  Suppose that  during each graveyard shift, a CNA receives 4 buzzer or alarm calls to rooms to change a resident for incontinence issues. Changing and cleaning up a soiled resident who is even  partially cooperative and ambulatory can easily take up to 20 minutes or more (I know from firsthand experience).  Try the same thing with a resident who is not ambulatory, paralyzed, or just plain feisty or combative. Now that 20 minutes can easily become an hour.  And that CNA may need to call in a helper to contend with that resident. So now let’s say you’ve had two 30 minute incontinence calls plus two difficult incontinence cleanups that took an hour each.  There went 3 hours of your 8 hour shift. There goes your timetable of checking on each of your residents once each hour.  You now have residents that you were not able to check on as quickly as you wanted.  You may also still have residents who may have soiled themselves in bed in their sleep and were not awakened to hit their room buzzers or door lights.  And what about what’s going on with those residents most at risk for flight or eloping attempts.  Which ones had time to get out of their bed, their room or get themselves locked in a closet, an elevator or a supply room?

In my opinion, the perfect staffing ratio at a nursing home ought to be one to one, or, one staff member assigned to two residents.  This however is not the reality of how residential coverage is dispersed.  It also, unfortunately, would be a prohibitively expensing proposition for what a nursing facility would have to charge the public.  At a minimum, graveyard staffing at nursing homes should at least be doubled up from where they are now.

The key to reducing (not eliminating entirely) the level of elopements that occur is a greater focus on education and action plans such as those listed here.

Better informed staff about their individual residents including those who are most at risk for flight (dementia patients rate high on such lists).

More exhaustive  internal “Code Silver” practice drills to nail down quicker response times and more thorough searches of a facilities physical layout prior to executing an external search.  Practice these enough so that every employee is familiar with the drills in terms of what to do, when to do it, and where they are supposed to meet at.  Also included in these drills should be knowing (and how to get there quickly) where an established fire and storm resistant ‘safe room’ is upon the premises.

Better use of camouflage and internal decorations to hide or reduce the visual attractions of vulnerable exits, doors, etc.

For more detailed information on how a skilled nursing facility or even an assisted living complex can address the elopement issue, I found the website www.elopement.org a helpful one.  I also found a very detailed outline on the topic of elopement at the University of Iowa, Iowa Geriatric Education Center: Info-Connect, Great Escapes: The Wandering Dilemma. 

Jeff Dodson

April 2nd 2014