Preventing Elopement in Assisted Living Facilities
What happens when a resident wanders out of an assisted living facility—and no one notices? Elopement cases often lead to tragic outcomes and raise serious questions about staff training and supervision. Families deserve to know how these incidents happen and how they can be prevented. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Kathy Sindoni to talk about the legal and safety issues behind elopement in assisted living facilities.
Sindoni:
In a memory care unit, all of the doors would have to be delayed egress. So that would be your fire exits, your main exits, and then if there’s an elevator, for example, outside, there may be mechanisms on that as well, like a keypad override to be able to get onto the elevator. So there’re, security measures.
Intro
Schenk:
Hey out there. Welcome back to the Nursing Home Abuse Podcast. My name is Rob. I’ll be your host for this episode. Today we’re talking about elopements as they happen to occur in assisted living facilities and what we can do to prevent them, but we’re not having that conversation alone. We have the fantastic Kathy Sindoni to walk us through that process.
Negatory buddy, the fantastic Kathy Sandon is here. Kathy has been a registered nurse for 32 years and has been engaged. Assisted living since 2001. Kathy is the owner and chief consultant of Substantial Compliance Consulting Group. She formally served as an administrator, director of nursing and case manager in the assisted living industry.
And additionally, Kathy is a certified legal nurse consultant who works with operators, attorneys, and insurance companies on healthcare and operational aspects of assisted living cases, and we are so happy to have her on the show today. Kathy, welcome to the show.
Sindoni:
Thank you. Thank you. Glad to be here.
What exactly is elopement in the context of assisted living?
Schenk:
We’ve had a few episodes talking about elopement, but it was from the context of a nursing home. So today we have, I’m so happy to have you on and talk about elopement as it is, as it occurs in assisted living, which as anybody knows, it’s different from nursing homes. So I guess the first question is, when we say elopement, what do we mean? What is elopement?
Sindoni:
Is really just a generic term. Generally used for people referring to people who have cognitive impairment, who are unsafe to leave the building unattended or unsupervised. Sometimes it’s used a little more generally if someone is a little higher functioning and drives a car, for example, and their whereabouts is unknown for an extended period of time, they may use that same term. But generally you’re talking about people with cognitive impairment.
This study investigates behavioral triggers and staff interventions for residents with dementia on the impact of preventive health measures in elderly populations.
How do elopement incidents typically occur in assisted living?
Schenk:
Can you describe Kathy, the typical elopement in an assisted living facility, what’s usually happening?
Sindoni:
There are two different things you have to think about. You’ve got the memory care units, which are in New York State, they’re called special needs.
And I specialize in New York state, so I know the New York State lingo the best. But we’ll just call it memory care to make it easy. So those are, areas that are, that have delayed doors and they’re, what often people, the lay person would refer to as a locked unit, where you have other sectors that are assisted living that do not have those, the delayed egress and they’re not a secured, quote unquote setting.
Researchers explore risk factors for elopement among cognitively impaired residents on the impact of preventive health measures in elderly populations.
So really can happen on either side and. In memory care, there’s certain ways that it may happen. It’s considered safer because of the delayed aggression, but there are a number of ways that can fail. And then on the non-secured side, may just be the first time that it’s happened for that resident that the day has come where they left and got lost.
They’ve been walking to the store regularly and done just fine. And today they couldn’t find their way back. So really two very different scenarios.
A nursing-led initiative to reduce fall risk and wandering is detailed on the impact of preventive health measures in elderly populations.
Schenk:
And I guess it. Thank you. And so I guess for me, as I’m sitting here, there are different ways to go in and out of buildings, right? So is the typical elopement as you’ve described, is it walking out the front door?
Is it like going out the fire alarm? Like the fire exit, do, how is it happening?
Sindoni:
It could be any of those things. And, outside of memory care in New York State, they do not allow any devices. Wander guard is an actual name brand of a system that can alarm. When someone goes out a door and they wear a pendant or a band or something like that, New York State does not allow any kind of a Wonder Guard system inside of memory care because the fear is that.
Staff will lose some of their diligence and rely too heavily on those devices. Whereas outside of memory care, they do allow that. And so then there are a number of ways that can fail. So I had it happen to me when I was an administrator where despite all of our testing of the equipment, it failed.
A resident got through without the alarm going off and she went down a fire escape. Unbeknownst to us, it really can happen in a number of ways. Had residents just slip out with a crowd, or a family’s visiting and a resident in memory care follows them right out the door and no one notices. So a number of ways it can happen.
This open-access paper highlights staffing-related barriers to preventing resident elopement on the impact of preventive health measures in elderly populations.
What measures can assisted living facilities take to prevent elopement?
Schenk:
So we have. A resident who is, let’s just say that they’re at moderate or high risk for elopement and wandering, what are some of the things that the assisted living facility can do to minimize that risk without being a restraint?
Sindoni:
And that you hit the nail on the head that the first thing you have to do is identify what the realistic risk is.
And there’s a whole conversation around that of how you can do that. Inside of memory care, they, obviously, the delayed egress itself is the greatest barrier that’s going to it. Delayed egress, just like it sounds, does not lock. So this idea of a locked unit is a little bit of a misnomer.
It will just alarm when you press the crash bar for 15 seconds, the door will open as a fire safety. So I can’t rely entirely on those doors. So there are a number of different things. We’ve seen operators do distractions that are near the doors. So for people, some residents have migrated towards the doors.
Those tend to be people who are. Busy. They’re active. That’s their personality. Maybe. I remember a story about a resident. It turned out after the fact, they found out that one of his jobs had been a nighttime security officer. So it was ingrained in his brain to go around and check doors.
Learn how poor design and inadequate policies contribute to unsupervised wandering on the impact of preventive health measures in elderly populations.
So it’s just it’s one of those things you have to really know your residents. You have to know their trends. You can’t disguise the doors because that’s a fire safety hazard as well. But having something like a large screen television that has cycling images that are comforting animals, scenery, things like that can be enough that a resident gets distracted and starts to migrate toward that television instead of activities.
But staff training is always at the core of all of this. It’s having that. That general, that knowledge of their general whereabouts at all times. Really easy to say, really hard to do in reality.
Families often ask, “Can I sue a nursing home for letting my loved one walk out unsupervised?” Here’s what Georgia law says.
Schenk:
Can you speak more about delayed egress? Like the act, to be quite honest, this is the first time I’m hearing that as a vocabulary, so to So talk more about that.
Sindoni:
Yeah. Delayed egress is literally just as it’s named it, it can’t lock. And not open because of potential for fire. So it has a, and most people have seen it’s a metal crash bar, they call it. It’s a horizontal bar that when you press on it, the door would open in delayed degrass, you have to hold that bar in for in New York state, it’s 15 seconds no longer than 30 seconds.
And the door will then open and it overrides the lock. So it’s locked up to that 15 second push. But the rules require that you have signage within 12 inches of the crash bar. So for residents, even residents with cognitive impairment, they can still read and many of them still follow instructions. So now you have this door as a protective measure, but you have a sign that tells the resident if they hold it in for 15 seconds, the door will open.
Facilities have a duty to prevent wandering and elopement in nursing homes.
And that’s there obviously, again, in case of fire and for visitors and such, but residents with memory impairment can still often read that sign and still figure out how to open the door. And in a memory care unit, all of the doors would have to be delayed egress. So that would be your fire exits, your main.
Exits. And then if there’s an elevator, for example, outside of, on the other side of the de delayed egress door, there may be mechanisms on that as well, like a keypad override to be able to get onto the elevator.
Watch this video if your loved one died after walking outside a nursing home unsupervised.
Schenk:
So I guess it wouldn’t be the case. And we’re talking about it, a memory care unit in assisted living where it would be opened only by a fob or some type of pen that only the employees know.
Sindoni:
Correct.
Schenk:
Okay.
Sindoni:
Correct. Just have a case where I do a lot of industry consulting. I do legal co consulting as well as industry consulting for operators, facilities staff. And one of my clients just had a service elevator that comes up into the center of the memory care unit and that has a keypad override and a resident ended up on that elevator doors closed, and the resident ended up on another floor.
Fortunately when the doors opened, other staff located the resident on the elevator and returned him to the unit. And that’s unusually of a memory care embedded inside of a building that also has other types of sectors. And what they think happened was that a staff member punched in the code, had to wait a period of time, got impatient and left, and this resident came along just.
Wandering the doors opened up and he, almost like a continuation of the hallway, just walked right onto the elevator. And this is ironic because it’s a resident they can’t even get to get onto an elevator in, nor, normal circumstances, he’s hesitant to even get onto an elevator. But with the doors wide open, he just walked right on the doors closed. Probably frightening for him as well.
Learn what steps to take when a nursing home resident walks out unsupervised.
Schenk:
Sure.
Sindoni:
And then fortunately. Other staff located him pretty quickly and he was returned to the floor. So there are a number of ways that things can break down.
What role do staff and caregivers play in preventing elopement incidents?
Schenk:
You’ve described delayed egress, you’ve described maybe putting a screen next to the door to distract.
These are devices, these are like mechanisms that we can do. You mentioned training briefly. Tell me more about what can the actual people working in the assisted living facility do to minimize these risks? What are the interventions that they themselves would do?
Sindoni:
Yeah, training is the heart of it all, because just like the situation I just described, reinforcing with staff how important it is to be diligent, be knowledgeable, and understanding of what a vulnerable population they are tasked with.
And also having this awareness in the New York State regs, it’s worded as a knowledge of general whereabouts. And obviously we’re not one-on-one, so we can’t be with each resident all of the time. So there are always potentials for gaps. So being really acutely aware we had another situation with a client where they had a large gathering outside of the memory care unit and it’s always nice to take.
In Episode 132: How Nursing Homes Can Prevent Falls, we cover environmental and staffing-related interventions.
Residents moved from memory care into other activities in the larger facility, but it was pretty crowded and each staff member had a number of memory care residents they were responsible for. And somewhere in the returning to the unit, one of the residents slipped right into a very large crowd of people who were exiting the building.
And the hard part about it is that they. They went up, they sat for dinner and no one seemed to notice that he wasn’t there. And so you get into things like head count and how did you know your five residents? How did you know one of them was not there until the police showed up at the door with this resident?
So now you have a really serious breakdown and the cameras that are in most buildings today give us a lot of clues to what, where the breakdown happened. But that’s staff awareness and staff understanding that they have a very big responsibility with these vulnerable populations.
Elopement and Wandering in Nursing Homes breaks down how and why residents escape unsupervised.
Schenk:
It’s tough. I know that, at least in Georgia, it’s literally written in, written into the code that you have to maintain awareness of every single resident.
So whether that’s putting a picture up next to the desk by the door so that you know that you’re not letting out a resident versus somebody that just wants to go it’s super important. I have a case just like that right now where the resident was new to the unit. And it’s possible that this was a temporary worker, or temporary agency worker.
So not familiar with anybody at the facility and the residents said I’m waiting for an Uber and got, just got let out because of that lack of awareness of who the residents are versus who the residents are not.
Sindoni:
Yeah, that’s right. It takes a lot of training and diligence.
How can families ensure their loved ones are safe from elopement risks?
Schenk:
Absolutely. Kathy, tell me about what are some of the top.
I would say tips are some of the best advice that you would give to a family that have a loved one in an assisted living facility who is at a high risk for elopement.
Sindoni:
One of the things that I, as I was thinking about this this podcast I thought a lot about a case that I had worked on where I think the bigger risk often is outside of memory care, because we do have those delayed aggressors, but how do we identify, I always say that a resident can be one day away from being a memory care resident or one hour, right?
Sure. Today I’m in the assisted living sector, and tomorrow I’m in the memory care sector. There’s no hard line. Rarely is it the day where, suddenly everything shifts and it’s black and white. So knowing our residents, knowing what to anticipate, case, I just worked on the facility, and had assessed that the resident was appropriate for memory care.
That was well documented and there wasn’t any language around elopement. And then the resident, they did end up the family. Argued that they really wanted him in the AL sector outside of memory care because he still had Parkinson’s and he had a lot, still had a lot of cognitive function, and these are sometimes the hardest cases.
Those residents who are still fairly high functioning but are right on the cusp, and they really wanted him to have that mental stimulation and be in a higher functioning crowd. So the facility agreed and put a wander guard in place and the wander guard. Functioned properly. He went out a door, the alarm went off, the staff claimed they responded timely, quickly.
Episode 43: The Danger of Nursing Home Elopement and Wandering reviews real cases and prevention strategies.
I find that difficult to believe because generally residents don’t move so quickly that you respond immediately and they’re just gone right off the grounds or, but, it wasn’t until during that whole investigation that the family said, oh yeah, they do this often. Check here.
As they were trying to locate him, and he was gone for 30 hours and found, thank God it was April, and not real, real cold, but found him laying on the ground and had been out for quite some time. So he was okay. He survived, but they’d known that information.
Beforehand. So I think being honest and a lot, it’s very tempting for families to not wanna share that information for fear of him not being able to stay in the non-secured area. And then the facility obviously has a responsibility as well to ask the right questions.
What steps should be taken after an elopement incident occurs in an assisted living facility?
Schenk:
Sure. We’ve covered that ad nauseum in this podcast about how it’s so important for the family to be involved in the planning process and definitely not withhold information.
That’s awful. ’cause that’s putting your level in danger. Every state is different. With respect to regulations for assisted living, for example, in Georgia we have something called the Maddie’s Law, which is the process that the facility has to follow once it’s known that the resident has eloped.
What is typically, what is the, what are the steps that the facility needs to go through once they realize that somebody is gone?
Sindoni:
Immediately they have to start a search or at least initiate that internal search. With memory care residents, they may very well just be in someone else’s room and there number of places you may find a resident so you can initiate that internal search, but you need to, they never.
Should let that go on for too long. And again, depending on inclement weather and other factors, you may not wanna go even 15 minutes before you’re bringing in authorities. It depends a lot on what you know about the circumstances. Like in this case where they know the door is alarmed and they say they responded.
It’s a little unclear what decisions were made after that because there was a. A significant period of time before they called the authorities and got the authorities involved and he could move pretty well. So he was long gone by that time and it made the search very difficult. And it was interesting in that particular case the assistant ag actually weighed in and said, you, 30 minutes at most before.
You bring in authorities. So yes, you can organize an internal search and then this should all be mapped out really carefully in policy and drills. Not enough facilities drill very few clients who actually drill elopements and they should. The ones who do are the ones who unfortunately suffered a bad outcome.
Episode 75: Preventing Elopement and Wandering in Georgia Nursing Homes highlights state-specific risks and laws.
Schenk:
And it’s interesting that you say that. That’s, I’m, that’s why I’m so happy that I have this podcast ’cause I get to learn every week. But you, like in Georgia, I think it’s the same, I think Maddie’s law is, there’s 30 minutes. Once you know that they’re gone or once, once you can’t find them, it’s 30 minutes.
Then you have to call the local law enforcement. And I’m always like, why isn’t it 60 seconds? But that’s why is you have to give the facility a chance to say, oh, she’s just down the hall in room, not necessarily outside. So I guess that makes sense. Then the issue just becomes how long is it reasonable for a facility to have to search within their own grounds for the person?
Sindoni:
Our New York City buildings can be 27 stories tall. So how long and you really have to know the layout of the facility is a big factor. How many places are there for someone to go? Sure. And how much time are you gonna spend looking ver versus if you’re one level, and you can cover a lot of territory very quickly.
How many staff times of day? If it’s the middle of the night, you have very few staff who can break out in groups and search an organized search. There are a lot of factors involved with how you, they should have a name for it, a code, green code, and a very specific procedure just like we drill fire drills.
That we truly, the best I have seen was I was walking with an administrator and the security staff were over there with staff members beating the bushes, literally looking in the bushes. And they were one of the unfortunate facilities that had a really un unfortunate outcome. So they drilled and they took it very seriously. But we need to not wait until we have a bad outcome.
In Episode 122: Five Ways to Prevent Falls in Nursing Homes, we provide actionable tips for families and staff.
Schenk:
And again, like every facility is different and then how people react is different. But like, when you say drill, what does that typically look like? Is it like person A goes to this wing or is it person B go? Like typically how does that work?
Sindoni:
Yeah, they do it differently, different facilities. But again, if you have a say code green they may call a code green over the pa. They may have a system that identifies if it’s in a certain sector of the building. And then they may many set it up so that everyone meets at a central, command center, so to speak, so they can organize their search.
And in a drill they’ll literally, sometimes they’ll even go so far as to have the resident participate, which they get a kick out of sometimes and go hide somewhere. See how long it takes the staff to actually find them. Those are actually the best drills.
Schenk:
Sure.
Sindoni:
And residents don’t seem to mind participating in things like that.
Schenk:
Well, Kathy we really appreciate you very much coming on the show and sharing your knowledge with us today.
Sindoni:
Happy to be here. Thank you.
Schenk:
Folks, I hope that you found this episode educational, perhaps entertaining. If you have an idea for someone that you would want me to talk to, please let me know.
If you have an idea of a topic that you want me to talk about, lemme know that as well. Please be sure to enter into the contest to win the Nursing Home Abuse Podcast mug. I can’t tell you how much space this has taken up in my house that no one is getting these mugs. You can even steal my answer.
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And with that folks. We’ll see you next time.
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