Safeguarding Residents – F689 Managing Elopement in LTC

Safeguarding Residents – F689 Managing Elopement in LTC

Elopement is one of the most urgent safety risks in long term care, often leading to devastating outcomes and serious regulatory citations. Ensuring the safety and well-being of residents is a top priority in every nursing facility, and diligent management is particularly important for individuals with cognitive impairment. Due to the severity of outcomes associated with elopement, these incidents are often cited at the Immediate Jeopardy level under F689 – Free of Accident Hazards/Supervision/Devices. Consider these strategies in your elopement prevention and management plan…

Understanding Elopement and Its Risks

Elopement occurs when a resident leaves the premises or a designated safe area without the facility’s knowledge or supervision. The dangers associated with elopement are significant: residents may be exposed to extreme temperatures, dehydration, injuries from falls, medical complications, or traffic accidents.

Important Note: Elopement isn’t limited to a resident exiting the facility entirely. A resident being “lost” or unsupervised within the facility—especially in hazardous or unauthorized areas such as mechanical rooms, storage areas, kitchens, or stairwells—can also be considered elopement under F689 if supervision and safety protocols are breached. A recent example involved a resident at nursing facility who was found in a kitchen-adjacent storage area without staff awareness—illustrating how elopement can occur within the walls of a facility.

Due to the severity of outcomes associated with elopement, the Centers for Medicare & Medicaid Services (CMS) frequently cites facilities under F689 – Free of Accident Hazards/Supervision/Devices, often at the Immediate Jeopardy level.

Real-World Examples of Elopement Incidents

Several examples of actual citations are listed below that highlight the dangers of insufficient supervision and potential gaps that facilities must work to close:

• • A resident with dementia exited the building after following a family member. She was not missed until dinner service and was later found a mile away, injured from a fall.
  • A resident with a BIMS score of 4 and a known Alzheimer’s diagnosis was discovered missing after local police found her near a high school. The facility had no functioning front door security system.
  • A resident with a history of exit-seeking behavior successfully left the building during dinner. Staff were unaware until they attempted to escort him to his meal. A visitor found him at a busy intersection.

Why Do Residents Wander or Exit Seek?

Exit-seeking behavior often stems from unmet needs. These may include:

• • A desire to “go home”
  • Pain or physical discomfort
  • Disorientation or confusion
  • Stress or environmental overstimulation
  • Boredom, loneliness, or excess energy
  • Medication side effects
  • Searching for a familiar person or item

Residents with mental health disorders or substance use disorders may also be at higher risk for exit seeking.

Proactive Prevention and Management Strategies

To effectively prevent and manage elopement, facilities should adopt a comprehensive, multidisciplinary approach that includes the following key components:

• Secure High-Risk Areas
  • Evaluate and secure exit doors, elevators, stairwells, and windows.
  • Maintain and regularly test door alarms and wander management systems.
  • Consider external hazards such as busy roads, water bodies, and extreme weather.
  • Implement clear protocols during emergencies like power outages or fire drills.
  • Discuss high-risk residents and potentially vulnerable areas regularly during Safety and QAPI meetings.
• Identify and Flag At-Risk Residents
  • Conduct risk assessments on admission, quarterly, after incidents, and upon changes in condition.
  • Develop individualized care plans using assessment data, including interventions such as alarm devices, environmental adjustments, and therapeutic activities.
• Strengthen Monitoring
  • Maintain a protected, updated list of residents at risk with photos and medical details.
  • Monitor residents during rounds and verify use of electronic monitoring devices.
  • Include elopement risk on care plans and assignment sheets.
  • Plan for close monitoring during facility evacuations.
• Respond Rapidly to Missing Residents
  • Respond immediately to door alarms with facility-wide head counts.
  • Implement a missing resident action plan that includes defined roles, search protocols, and investigation procedures.
• Train and Test Staff Responsiveness
  • Provide regular training on identifying, preventing, and responding to elopement risks.
  • Train staff to recognize high-risk situations like shift changes or large events.
  • Perform competency checks and elopement drills across all shifts.
  • Address gaps in practice related to resident identification systems and alarm responsiveness.
• Use Data to Drive Safety Improvement
  • Include elopement incident reviews in QAPI meetings.
  • Use data to identify trends and implement continuous quality improvement initiatives.

A Shared Responsibility

Preventing elopement is not the sole responsibility of nursing or security staff—it requires organization-wide awareness, consistent policy implementation, and ongoing education. Facilities that actively engage all departments in prevention efforts and continuously review outcomes are better positioned to protect their residents and maintain compliance with regulatory standards.

By prioritizing proactive risk management strategies, nursing facilities can better safeguard their residents, reduce liability, and foster a safer, more supportive environment for those most vulnerable to wandering and elopement.

Next Steps: Join Proactive on May 20th for virtual training focused on Elopement as part of our series Reducing Litigation Risk for SNF & AL. Need F689 training today? Access F689 – Free of Accident Hazards/Supervision/Devices training on-demand.

Contact Proactive to schedule a QA site visit focused on Falls, Accidents and Elopement prevention and management systems, or for assistance in managing Immediate Jeopardy matters.