Never Event: Elopement in Nursing Homes – A Type of Neglect

It’s one of the worst events that can happen at a healthcare facility.   In February 2011, a nursing home resident wandered away in a blizzard, unnoticed by staff. He was wearing only pajama pants, a sweater, canvas shoes and a knit cap. A technician driving to work found him half an hour later at a busy intersection, wet and covered with snow, government inspectors wrote [2].Tragically, this is hardly an isolated incident.  The elopement of a resident from a long term care facility is one of the never events that nursing homes dread. The term, first coined by Dr. Ken Kizer in 2001, was used when discussing serious medical errors which are clearly identifiable, measurable and preventable, including fall with injury, pressure ulcer, dehydration, constipation and elopement. A nursing home may be liable for negligence if it does not take the proper steps to prevent elopement or wandering, which is a type of nursing home abuse that can pose serious risks for your loved one’s safety.  Florida law defines “elopement” as an adverse incident where facility personnel could exercise control and which is associated in whole or in part with the facility’s intervention  rather than the condition for which such intervention occurred.[1]  Elopement is when a resident leaves the facility without following facility policies and procedures for signing out.[2]

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Alarming statistics

  • It is estimated that up to 31% of nursing home residents and between 25% and 70% of community-dwelling older adults with dementia wander at least once. A 2006 study reported that one in five people with dementia wander[3]
  • The primary cause of elopement-related deaths include:
    • being struck by a vehicle.
    • exposure to heat or cold.
    • drowning
    • abuse (physical and sexual.)
  • In forty-five percent of cases, the event occurred within the first 48 hours  of admission
  • In eighty percent of cases, the resident was known to be a wanderer with prior elopements.[4]

Risk Factors for Wandering  in older adult patients ([5]:

  • Memory loss
  • Physical needs (e.g. toileting)
  • Social needs
  • Insomnia
  • Side effects from medication
  • Disorientation

 Preventing Elopement
As published by Repetoire magazine in “Preventing Elopement”, nursing home facilities need to consider precautionary measures to decrease the risk of elopements. Preventing elopement should begin with the admissions process to a nursing home. Residents and facilities should be appropriately matched, such that a particular nursing home can meet the needs of each resident it admits. Next, an individual care plan must be developed to address those needs, based on whether or not the patient has a history of unsafe wandering or elopement. The ideal care plan is resident-specific and adapts to any changes in a resident’s condition that would impact the care plan. To ensure that it meets a resident’s changing needs, the plan must be continually evaluated.
There is a wide array of products that facilities can utilize to continue to adequately protect their residents from elopement. For example, wristwatch transmitters worn by patients are designed to continuously send silent signals through a wireless network to a base unit, which alerts caregivers when residents leave or enter a restricted area, approach certain exits or even remove the device.  Some transmitters and monitoring devices send audible or visual alerts to staff, or activate magnetic locks on doors.
Negligence Related to Elopement and/or Wandering
When a nursing home resident who is not capable of protecting himself or herself from harm, or who is impaired mentally, elopes or wanders and gets hurt, the nursing home may be negligent. At Edwards & Ragatz, P.A., we know there are many situations in which the nursing home may be responsible, including:

  • Failing to hire enough staff to properly supervise residents
  • Failing to properly train staff on how to supervise residents
  • Failing to have alarms or other devices to prevent elopement and/or wandering
  • Failing to take the right measures to allow residents to exit and enter the nursing home unattended
  • Hiring staff members who failed to properly respond to an alarm previously
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If the nursing home neglected to do any of these things or allowed the resident to elope or wander, they may be liable for the injuries your loved one suffered as a result of the elopement or wandering. Edwards & Ragatz, P.A.  may be able to investigate for you if the nursing home is at fault and should be held responsible.  Contact us by filling out the online form to  or call us toll free at 800-366-1609.


[1] Florida Statutes 400.147(5)

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