Elopement in Residential Facilities Expert Article

In supervised care environments, the term “elopement” describes when a resident leaves the premises without authorization and/or necessary supervision. If elopement occurs, the individual who left the premises unsupervised is at a substantial risk of injury and/or death.

This article examines contributing factors to the occurrence of elopement in residential facilities, the potential consequences of elopement, and some of the factors that should be considered when evaluating why an elopement incident occurred and if the facility met the standard of care.

Supervised care elopement expert witness

Frequency and Consequences of Elopement in Residential Facilities

Many individuals admitted to a residential facility or agency require assistance with their medical, emotional, behavioral, or physical needs. As a result, supervision and care are needed to ensure their safety. 

According to the Journal of Advanced Nursing, approximately one in three nursing home residents who have dementia and/or cognitive impairments will elope from the facility at least once during their residency. If the resident is not located within the first 24 hours, there is approximately a 25% chance that they will not survive. 

Children, adolescents, and adults within residential facilities are also prone to elopement. It is common for this population to have developmental disabilities including autism spectrum disorder and intellectual disabilities or mental health conditions which present as behaviors that compromise their safety and well-being. As with adults, the consequences of elopement in children can often result in severe injury or death. Deaths or severe injuries associated with elopement are serious, reportable events to state governing agencies.

In addition to individual harm and the emotional burden on affected families, elopement incidents can carry a significant financial burden for the facility. Reported incidents may require increased monitoring and supervision within the residence, and potentially a re-evaluation of existing policies and procedures. Facilities may also face negative citations from governing agencies with required corrective action plans, and quality ratings may decline.
Elopement Prevention

Facilities need to have processes in place to assess each resident’s risk of elopement, and strategies to prevent elopement.  Assessments should be performed at the time of admission, and if there is a change in condition or behavior. These assessments typically include: 

  • Conducting a comprehensive safety history including identifying the resident’s cognitive and mental capacity to determine the knowledge, insight, and judgement of the individual and the consequences of leaving the premises unsupervised.  
  • Speaking with family members and other community providers is key to determining the level of elopement risk. If the individual has a history of elopement at home or in a previous residential environment, it can be an indicator that they may be at risk of elopement, especially in a new environment.  
  • Determining if they have behaviors such as wandering, and/or if they receive medications that may cause restlessness or anxiety. These behaviors also contribute to the likelihood of elopement.

Determining the Standard of Care and Causation in Elopement Cases

The Agency for Healthcare Research and Quality notes that breakdowns in individual assessment and team communication are top contributing factors in elopement. Staffing shortages, along with a failure to secure the physical environment and follow the individual’s care plan also contribute to the likelihood of elopement in these settings.

The standard of care in each case will be determined based on a number of resident-specific risk factors. Examples of precautions that may be relevant include the placement of at-risk individuals where they can be closely monitored and away from exits; access controls at exits, alarm systems, and electronic monitoring devices may also be relevant. 

Even facilities with advanced security systems can experience elopements resulting from procedural failures. Procedural causes of elopement may include:

  • Breakdowns in policies and procedures – Well-defined organizational policies for preventing and responding to an elopement need to be in place and well understood by all employees involved. These policies and protocols must be clearly communicated to all personnel and when appropriate, be specific to the identified individual of concern. Personnel need to be aware of the rationale for the policy, as well as other corrective actions. 
  • Communication failures – Staff trainings and education protocols must be comprehensive, ongoing, and repeatable; especially if there is a change in a resident’s medical condition or behavior. Without proper communication among all staff members, a breach in policy and protocols is more likely to occur, causing resident safety to be compromised.
  • Failure to follow the plan of care, including supervision levels – To protect the well-being of residents, a facility needs to demonstrate how they assessed the resident’s safety risks and their measures to prevent elopement. Depending upon the circumstances, this can be considered a form of abuse or neglect.

When investigating these matters, careful consideration needs to be placed on these standard of care issues. Facilities have a responsibility to ensure they are properly staffed to meet the needs of at-risk individuals, staff is trained accordingly, and policies and procedures are developed, communicated, and implemented. 

Elopement Expert Witness Investigations 

Among the supervision experts at Robson Forensic are nurses and nurse practitioners, social workers and psychologists, special education and child / adult care program coordinators. They have hands on experience working in organized care settings, implementing and evaluating the processes and procedures used to ensure resident safety. This includes, among others, effectively screening staff during the hiring process, training and retaining staff, and reporting/investigating incidents. 

For more information, submit an inquiry or call us at 800.813.6736. 

Featured Expert

Danielle Dieterich, Supervised Care & Behavioral Health Expert

Danielle Dieterich, MA, JD

Supervised Care & Behavioral Health Expert
Danielle Dieterich is a Supervised Care & Behavioral Health Expert with two decades of experience in the management of clinical programs and residential care facilities including day habilitation,… read more.


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