Resident Sexuality: Adapting Your Policy
GuideOne Risk Resources for Health Care
1111 Ashworth Road
W. Des Moines, IA 50265-3538



Your Education Guide to Resident Elopement

A resident elopement is defined as a dependent resident in a licensed facility who leaves without staff observation or knowledge of their departure.

Here are some alarming statistics:

  • Upwards of ten percent of all lawsuits involving nursing homes deal with elopements.
  • 79 percent of these lawsuits involve the death of a resident.
  • The primary causes of elopement-related deaths include:
    • being struck by a vehicle or train;
    • exposure to heat or cold (e.g. frostbite injuries, heat stroke, etc.);
    • drowning;
    • abuse (physical and sexual);
    • fractures or head injuries;
    • falling off roofs or out of windows; and
    • falling into ravine or road ditch.
  • In 80 percent of cases, the resident was known to be a chronic wanderer with prior elopements.
  • In 45 percent of cases, the elopement occurred within the first 48 hours following admission.
  • Incidents of elopement occur in every state and in all levels of care.
  • Unsafe wandering and elopement are associated with falls and related injuries.
  • The average out-of-court settlement (2009) was $393,650. In Delaware, a jury awarded $18 million dollars against a LTC facility for a single elopement.

Elopement-related deaths create mental anguish for both families and nursing home staff. The courts have shown to be harsh in ruling facilities were negligent in their duty to provide a safe environment.

The discovery of an elopement by a resident that was a known risk almost always results in a G or J deficiency tag if surveyors find the facility at fault (F323).

The CMS guideline for determining immediate jeopardy is failure to prevent neglect [due to] lack of supervision of cognitively impaired individuals with known elopement risk (Appendix Q – State Operations Manual).

Most states require mandatory reporting of elopements, especially if the outcome involves harm to the resident.

Why Should I Be Concerned?

Resident elopements happen so infrequently that it is uncommon for a facility to have a written elopement plan and program. This is a mistake that can lead to litigation and disciplinary action. Pull your team together and develop a plan now! Review the plan at least once per year and after every elopement incident.

Many elopements occur in the late afternoon and evening hours (often due to Sundowning Syndrome) when a greater number of staff members are not available.

Many Administrators and DONs have a false sense of security thinking an elopement will never occur in their facility because exit doors have alarms. The problem is many elopements occur because the resident was able to punch the numbers in the key pads, staff turned the alarms off or the resident just simply walked out through the doors behind staff or visitors.

No facility is elopement-proof, which is why planning is essential. That is why Briggs Healthcare and GuideOne Risk Resources for Health Care teamed together to develop a free Resident Elopement Educational Guide filled with facts, information on prevention and responding to a resident elopement, tools and references and additional resources.

Copyright © 2012 GuideOne Risk Resources for Health Care, a division of Lutheran Trust, Church Asset Management. All rights reserved.
GuideOne® is the registered trademark of the GuideOne Mutual Insurance Company. All rights reserved.