It was a chilly, February afternoon in Elizabeth City, North Carolina when Ruby Whedbee, a 90-year-old resident who suffered from dementia, wandered away from the Brookdale Elizabeth City senior living community. While an extensive search was conducted by both the police and community staff, Ruby was not found until the following day. By the time they found her, she had already passed away.

Ruby had taken shelter in a greenhouse about half a mile away from the senior community. While the official cause of death wasn’t released, it’s suspected that she may have died due to the low outdoor temperatures. The temperature was said to have dipped as low as 40 degrees while she was gone.

Back at the senior living community, it was found that exit doors were accessible to residents and weren’t alarmed at the time of Ruby’s elopement. The community claimed they had a wander management system, but it had been deactivated and residents weren’t wearing electronic signaling devices that would have set off the alarm if it had been working properly.

Due to the unfortunate death of Ruby and the investigation findings within the community, the community’s license was downgraded and they were told not to accept new residents. With this incident in mind, it’s clear that every community must effectively educate staff on elopement and evaluate their current policies and procedures.

Tips for Resident Elopement Prevention

In order to help stop elopements before they occur, it’s suggested that the following be completed.

Screen Residents for Elopement Risks

Since elopements don’t happen extremely often, elopement assessments are often overlooked when new residents arrive at communities. It’s advised that every resident be evaluated to see if they have enough cognitive awareness to know that they need to remain within the building unless accompanied by staff or a family member.

Wandering risk assessments should also be conducted multiple times a year to check for any cognitive decline that may put them at risk for elopement. If an assessment concludes that a resident is at risk of wandering, they should be secured in a dementia-specific neighborhood with devices that help to prevent wandering.

Strategically Assign Rooms to New Residents

In addition to evaluations, new residents should be placed in rooms as far away from exits as possible. This is due to the fact that about half of the total number of elopements occur within the first few days of a new resident residing in a community. It’s recommended that their rooms be placed near community areas or areas that are heavily supervised until their behavior patterns have been observed and established by staff.

Assess the Community’s Security

Security technology is vital when it comes to elopement prevention. Security monitoring devices such as cameras should be placed at all exits to ensure each resident is accounted for. In the event that a resident goes missing, the cameras can be checked to find out where the resident was last seen or which door he or she walked out of.

Magnetically-locked, key-coded doors and door alarms are also necessary. Magnetic locks ensure no one can enter or leave without permission. Door alarm systems will secure community doors to help prevent residents from wandering off. They’ll also immediately notify staff if someone tries to leave while unsupervised.

Both security devices and door alarms should be monitored on a regular basis to ensure they’re working properly. Proper documentation must also be done, guaranteeing there’s a record of when security items were last checked.

Make sure to understand your individual state requirements and regulations regarding locked or alarmed doors. Make special note of any expectations for locks to release during a fire or emergency event to allow for egress. These regulations often apply to doors as well as gates in outdoor courtyard areas.

Implement Electronic Tagging Devices

An added blanket of security in preventing resident elopements comes from the use of electronic tagging devices. These electronic devices may be connected to the community’s door alarms or even to GPS, allowing residents to be located wherever they may be. They generally come in the form of a necklace or wrist bracelet, but some are inserted into shoe soles.

Train Staff Thoroughly

Ensure that staff is aware of and trained on your community’s policy to check on all residents who exhibit potential wandering behaviors. Many communities require one or two-hour check-ins to ensure all residents in the community are where they should be.

Staff should also be aware that they need to educate any visitors about the safety precautions that need to be taken to prevent resident elopement. The more people aware of the issue, the better.

How to Handle Resident Elopements

It’s vital that communities have a plan in place in the event that an elopement occurs. Make sure that these important steps are highlighted in your emergency preparedness plan:

  1. Upon discovering a resident is missing, the staff member must notify the manager on duty immediately.
  2. The resident sign-out book must be checked to see if the resident has been checked out recently.
  3. If the resident hasn’t been checked out recently, they should be paged over the public address system.
  4. If the resident can’t be located, the manager must coordinate a search for the resident, including searches of every room and any outdoor areas surrounding the building.
  5. If the resident cannot be found after a search is conducted, the manager should notify the administrator and wellness director. The person notified becomes the facility search coordinator.
  6. Within 30 minutes, the search coordinator must notify the resident’s family or primary contact that an elopement has occurred.
  7. The missing resident must be reported to the police department and an up-to-date photo and description should be provided to assist with their investigation.
  8. Another indoor search for the resident should take place.
  9. If the resident is still not found, the search coordinator must notify the appropriate entities according to state requirements and the local Office of Aging.
  10. The search should be expanded into the community with teams of co-workers searching assigned areas. Fliers should be distributed at that time and the coordinator should contact the resident’s family member or primary contact hourly to report the search progress.
  11. Upon finding the resident, a full physical and emotional evaluation should be conducted.
  12. All parties must be notified that the resident has been found and a report should be created about the incident.
  13. A meeting should be held with staff members to review the incident and current elopement procedures. Changes to the procedures can be made based on the recommendations from staff in order to further prevent future elopements.

To make your employees aware of the procedure, you can distribute or hang up this helpful flow chart around your facility!

assisted living flow chart for elopement management

Looking for resources to help you effectively train staff on both mental disorders and how they play a role in elopement? Take a look at our Alzheimer’s and dementia resources!