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9 Stefanacci and Haimowitz noted that 72% of residents who have eloped in the past will attempt it again. Claims against facilities where residents eloped indicate that 8 out of 10 elopements involved repeat wanderers. They found that 45% of elopements where claims against facilities were filed occurred within 48 hours after admission. Findings of the study by Kwok and colleagues showed there were higher chances of getting lost in the community with greater cognitive dysfunctions. A telephone survey of people in Hong Kong who were providing care for older adults with dementia showed that 27.5% of the dementia patients in the study experienced an incident of getting lost. Almost half (45.5%) of the caregivers located the older adult who was missing within 1 hour, and by 24 hours almost all (96%) of the missing older adults were found.

10 Stefanacci and Haimowitz noted that 72% of residents who have eloped in the past will attempt it again. Claims against facilities where residents eloped indicate that 8 out of 10 elopements involved repeat wanderers. They found that 45% of elopements where claims against facilities were filed occurred within 48 hours after admission. Findings of the study by Kwok and colleagues showed there were higher chances of getting lost in the community with greater cognitive dysfunctions. A telephone survey of people in Hong Kong who were providing care for older adults with dementia showed that 27.5% of the dementia patients in the study experienced an incident of getting lost. Almost half (45.5%) of the caregivers located the older adult who was missing within 1 hour, and by 24 hours almost all (96%) of the missing older adults were found.

11 Long-term care administrators are required to have a facility that keeps their residents safe, which includes protecting them from elopement. Once a resident has been identified as being high risk for elopement, staff should develop a plan of care that includes prevention strategies and include a response plan in its emergency and disaster policies and procedures. A quick and organized staff response to a missing resident can help prevent injury and possible death. In an article by Stefanacci & Haimowitz about elopement from assisted-living facilities, the authors explain that if a resident is not found within 24 hours after being reported missing, there is a 25% fatality rate. According to data published in 2015 by the Alzheimer s Association in its Facts & Figures report, costs for individuals with Alzheimer s disease and other dementias are estimated at $226 billion for 2015 with a projected to increase to more than $1 trillion in

12 Senior managers need to ensure that their long-term care facility s policies are congruent with national guidelines and standards. National standards were developed to help meet the goal of having healthcare facilities provide a safe environment for their patients/residents. Organizations that create standards of practice include the Agency for Healthcare Research and Quality (AHRQ) and The Joint Commission (TJC). National Patient Safety Goals were created by The Joint Commission and include goals such as identifying patients correctly, using medicines safely, preventing infection, preventing patients from falling, and identifying patient-safety risks such as elopement. Guidelines of care are also created by third party payers and governmental agencies to guide reimbursement fees. For example the Centers for Medicare & Medicaid Services (CMS) reduce financial reimbursements in the case of injuries, such as patient falls incurred while in a health care setting.

13 The Patient Safety and Quality Improvement Act (2005) established patient safety organizations (PSOs), and regulations governing PSOs. In 1999, the Institute of Medicine (IOM) advised states of the need to create a mandatory reporting system of adverse events that occur in healthcare facilities. The purpose of the reporting system is to hold healthcare facilities accountable for errors and to improve weaknesses that cause adverse events to occur. Once an adverse event is reported, a root-cause analysis can be required followed by a plan to correct any identified weaknesses in the system. As of 2007, legislation was passed in 26 states that required mandated reporting of adverse events. As a senior manager of your long-term care facility, it is important for you to be aware of whether or not your state has a reporting system in place.

14 The Joint Commission s updated sentinel event policy includes a category of patient safety events. The requirements for steps to be performed after a sentinel event will help to determine contributing factors and causes. The Joint Commission categorizes elopement situations that lead to death, permanent harm, or severe temporary harm as sentinel events if the resident is in a care setting that provides round-the-clock care. Other types of patient-safety events are identified as adverse events, no-harm events, and close calls. Hazardous conditions are defined as circumstances that increase the probability of an adverse event. If an adverse event occurs, the leaders of the facility should be notified immediately, allowing for a prompt investigation of the situation. Whenever a sentinel event occurs, it signals the need for an immediate evaluation and response.

15 The Joint Commission provides standards for appropriate responses to sentinel events. Senior managers should be aware of the need to provide The Joint Commission with a systematic analysis following a sentinel event occurrence. This includes completing a root-cause analysis that will focus on the facility s systems and processes in order to identify what caused this event to occur. After completion of the systemic analysis, an action plan should be developed to list the strategies that will be used in the future to prevent similar sentinel events from occurring. The action plan should include the actions that the facility plans to take, who is responsible for implementation of the plan, timelines, tools for measuring effectiveness, and strategies for sustaining the change over time. The Comprehensive Systematic Analysis and Action Plan should be submitted to The Joint Commission within 45 business days after the occurrence of the sentinel event.

16 Do you have a formal plan in place to prevent elopement in your long-term care facility? Best practices for the care of older adults who have dementia and are at risk for wandering, include identifying risk upon admission, providing appropriate supervision, reducing environmental triggers for wandering, and using individualized nursing interventions to address the causes of wandering behavior. It is necessary to have all staff educated on the elopement prevention plan of care so that the multidisciplinary team knows what to do and how to act quickly as soon as a resident is found to be missing. Many residents who wander are confused and are at a higher risk for falls. Staff must document that the policies were implemented.

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18 The Oxford Dictionary defines an ombudsman as an official appointed to investigate individuals' complaints against maladministration, especially that of public authorities. In the United States, it is required for each state to have a long-term-care ombudsman appointed. Ombudsman programs and the specific duties of a state s ombudsman vary from one state to another. In West Virginia, some of the responsibilities of the ombudsman role include providing outreach services to residents; identifying, investigating, and resolving complaints made by longterm care residents; coordinating efforts with other agencies for long-term care; arriving for routine and unannounced visits to long-term care facilities; and promoting community awareness about long-term care issues. Types of concerns that are addressed by an ombudsman may include quality of care issues for long-term care residents, billing issues, and appeals for facility transfer/discharge. Other situations that an ombudsman can address include incompatible roommate complaints in a nursing home facility, nutrition concerns, privacy issues, or suspected abuse/neglect. Any type of concern that a long-term resident has can be addressed by the ombudsman.

19 Federal rules dictate the resident s right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. Nursing homes need to meet the minimum quality and safety standards as required by Medicare and Medicaid in order to be eligible to receive payments and avoid termination from certification. Addressing the environmental design of a facility can help reduce behaviors that lead to aggression and agitation. Utilizing environmental interventions such as personalizing resident room settings, limiting external stimulation and information processing will help keep residents calm. In the past, residents lived in regimented environments and were at times medicated to prevent wandering. Today, long-term facilities are moving to a more flexible environment. Murphy and colleagues describe a wander garden that is a secure outdoor area that provides residents with the ability to independently walk in a natural outdoor setting. Studies demonstrate that one in five dementia patients will wander.

20 Federal rules dictate the resident s right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. Nursing homes need to meet the minimum quality and safety standards as required by Medicare and Medicaid in order to be eligible to receive payments and avoid termination from certification. Addressing the environmental design of a facility can help reduce behaviors that lead to aggression and agitation. Utilizing environmental interventions such as personalizing resident room settings, limiting external stimulation and information processing will help keep residents calm. In the past, residents lived in regimented environments and were at times medicated to prevent wandering. Today, long-term facilities are moving to a more flexible environment. Murphy and colleagues describe a wander garden that is a secure outdoor area that provides residents with the ability to independently walk in a natural outdoor setting. Studies demonstrate that one in five dementia patients will wander.

21 There are numerous type of surveillance technology available to help keep a long-term care facility secure from the community at large and to prevent elopement. One type of surveillance technology includes environmental sensors, such as motion detectors that can send alerts to staff members. Motion detectors can also be used in the resident s room and can be deactivated, based on each resident s needs. DECT phones help to enhance direct-care staff communication and also include an alarm that can be triggered by sound or motion sensors in the residents rooms. Video monitoring refers to hallway cameras and acoustic sensors that transmit sounds to a computer or DECT phone, can be installed in rooms and transmit to a central location. Tagging systems include use of electronic tagging bracelets that trigger the facility s automatic doors to respond when the bracelet comes close. Tracking systems that utilize GPS technology can be sewn into the resident s clothing and linked to a computer so that the residents location can be tracked. Automatic doors can be armed with an access code known only to the staff and those who come routinely for visits.

22 The Alzheimer s Foundation of America provides numerous strategies that can be used for finding and identifying residents who have become lost or are missing. Residents at high risk for elopement should have a number of different forms of identification. Examples are identification bracelets and clothing labels. It is helpful if the bracelets include the individual s name and contact information for emergencies. An identification system works well when it can only be removed by a staff member. The emergency call number may or may not be connected to a central registry, but a registry program can help to make this process quicker.

23 Senior managers and/or law enforcement can institute the use of technology to aid in locating a resident who is missing. Technology methods used for assisted rapid-response programs include the use of radio signals and tracking devices, which can include global positioning satellites and cellular triangulation, such as of cellphone signals. The cost of these services are usually paid out of pocket since insurance companies don t routinely cover this intervention. It is also recommended that law enforcement agencies provide education about prevention of elopement and resources for the facility and local community of the lost resident. This can include information about how people with dementia get lost, ways to identify who they are, and how to interact with a person who has dementia when they are found after being lost in the community.

24 To help find a missing resident as quickly as possible, The Alzheimer s Foundation of America recommends seeking help from the general public. One way to do this is through the Silver Alert program. Silver Alert was modeled after the Amber Alert system developed to help find missing children. These systems use Robo-calling to alert the community to look for someone who is missing. Various types of media are used to disseminate information about the Silver Alert situation, including digital roadway signs, television, and communication systems that get information out by mass notification using automated systems. The automated systems send out notifications by cell phones, SMS text, s, and fax. One type of emergency notification system is REVERSE 911, which combines mapping and database technology to notify people who live in specific geographic areas when an emergency situation such as a Silver Alert arises. This helps to quickly alert the surrounding public of the situation so that they can aid in locating the missing person.

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26 Senior managers should provide supervision for development of a response plan to find a missing resident. In a 2010 study at the Los Angeles Veterans Administration (VA) facility an adequate response plan to find missing patients who wandered or eloped was not in place. They performed root-cause analyses of a series of incidents. Most of these situations occurred during the daytime hours. The first major flaw they found in their attempts to locate a missing patient included the lack of using search grids. When staff is directed to search a unit for a missing patient, a deliberate and coordinated effort should be in effect with the use of search grids. Staff should be educated on the search grids prior to a missing patient situation. Mock drills were conducted which included having each unit within the VA facility utilize a generic sample grid to search for a missing resident.

27 To help prevent elopement, it is helpful to make sure that all staff members have been trained to provide evidence-based care for dementia residents. If your long-term care facility is funded by CMS, it is a requirement that nurses aides working in nursing homes receive training on individualize care, including dementia area. This requirement was mandated in the Omnibus Budget Reconciliation Act (OBRA) of In order to provide high-quality and evidence-based care to residents in long term care facilities, the staff need to be properly trained, which includes information about caring for residents with dementia. Community-based participatory research (CBPR) provides a model of training that helps to improve the actual use of the information into resident care. This community of attendees includes older adults, family members, facility management, senior managers, researchers, expert trainers, and professional and paraprofessional staff. Key to the success of the training programs is the support of senior managers, who have the power to promote the attendance of the employees for the training sessions. Residents and family members can provide feedback to management that helps guide the specific focus of training.

28 To avoid injuries related to a resident s increase risk for wandering or elopement, the senior manager should see that residents at high-risk for elopement are placed on the appropriate increased amount of supervision. This higher level of supervision should involve maximum staff surveillance, including placing the resident in a room in view of the nurse s station, having the nurses check on the resident regularly and during shift changes, and having 1:1 supervision with use of volunteers, sitters, or specialized staff. In addition, special color-coding of the residents clothes, use of alarms on bed and chairs, and tagging system alarms can also be used to help increase supervision. It is also very important to know which patients are at increased risk of eloping, so that staff can be aware of their location when exit doors are opened. Supervision can also be increased for patients at high risk for elopement by checking on them at least every 15 minutes.

29 After reducing the environmental triggers, the next step is to individualize care with interventions to reduce wandering behaviors. Begin with asking the resident s family members if they know what may be causing the resident to wander. If a reason is known, then specific interventions can be utilized to help limit the wandering behaviors. For example, if wandering is due to security issues, find out what specific anxieties they have and reassure them of their safety. Since any change can cause confusion, it is helpful to avoid room changes. Interventions recommended by Smith & Buckwalter to assist with reducing agitation for the resident with dementia include sensory enhancement, socialization, and structured activities. Sensory enhancement is the use of aromatherapy, music, massage/touch therapy, and Snoezelen. Snoezelen is described as an environmental intervention that can enhance relaxation with the use of colored lights, aromas, gentle music, textured objects, and breeze machines to create a soothing environment for the resident s senses.

30 Senior managers need to oversee the development of protocols for the staff to appropriately respond to an elopement situation. Mock drills can be used to routinely test the elopement response protocols. Protocols should include contacting the appropriate law enforcement agency and family members in a timely fashion. Security staff should be educated on resident wandering behaviors, procedures for searching for a missing resident, and actions for rescuing a lost resident. The protocols should include the importance of having current pictures of residents who are at high risk for elopement. In addition, place a piece of the resident s clothing into a closed plastic bag to aid search dogs in locating a lost resident. For residents who have been diagnosed with dementia, encourage registration with the Alzheimer s Association Medic Alert + Safe Return program. The literature indicates that approximately 80% of older adult individuals who were missing were found within a 12 hour timeframe. Of those found in this timeframe, 36% were found by law enforcement and 34% were found by citizens in the community.

31 Information that addresses procedures for the staff to follow once the elopement has been resolved should be included in the facility s elopement protocol. First, the staff should assess the status of a resident who has been located after eloping. Second, examine the resident to determine if any injuries are present and take the appropriate measures if injuries are found. Third, check the resident to make sure he/she does not have any objects that can injure him/her or others; remove any objects found. Finally, reassure the resident that he/she needs to continue having care in the facility. It is essential that the staff document details of all interventions and procedures performed throughout the elopement incident.

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33 Here are some examples of elopement situations that occurred in long-term care facilities year-old male resident with Alzheimer s dementia, wheelchair bound was relocated a few times by staff moving him away from the elevator. One day, he was found outside on the sidewalk year-old female resident with Alzheimer s disease was found lying on the ground outside of the facility. Although an employee heard the alarm and looked outside the door, he or she was assumed that it was a false alarm since no one was visible. It wasn t until 2 hours later that an administrator of the facility walked outside and found the resident. She was conscious, but she was covered with ant bites and had been sunburned. A lawsuit was filed against the facility requesting $1 million by the plaintiff.

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