Wandering and Elopement Resources.
NCCDP Endorses Project Lifesaver
- Alert Systems for Missing Adults, CMS report for Congress 2009, Silver Alert Legislation, Golden Alert Legislation
- Alzheimer Dandyfunk for Caregivers - List many products Motion sensors and Tracking
- A Shoe for Wanderers - (with tracking device), October 14 2011 NY Times
- Best Practices for Preventing Elopement With Patients With Dementia in Hospitals
- FREE VIDEO TO VIEW
- DBS Productions - Alzheimer's Links
- dbs Productions - The Source of Search and Rescue Research, Publications and Training - Wandering Incident: Preparedness
- Dehydration Risk Assessment Tool
- Dementia Care Mapping Book
- Dewing Risk for Wandering Risk Assessment Tool
- Elopement Resource Manual
- Elopement Resource Manual from Healthcare Association of New York
- Elopement Risk Assessment Form
- EM Finders, Elopement Risk Assessment Form, Elopement Risk Assessment Decision Tree
- First Responder Training - Wandering and Elopement
- GPS Shoes
- Guide for the Use of Disguised Doors and other Preventive Exiting Strategies for People with Dementia
- Guidelines for Best Practice Elopement Prevention Assessments, policies and forms
- Keruve Family Direct Locator - GPS Watch and Receiver
- Memory and Behavior Problems Checklist—1990R
- Missing Alzheimer’s Disease Patient Initiative
- Missing Resident Protocol and Risk Assessments Hazardous Wandering and Elopement Continuing Care Risk Management System
- Myth Busting: The Wandering Issue
- National Institute for Elopement Prevention and Resolution
- New York State EDGE Program Electronic Dementia Guide for Excellence
- Personal Alarms: Safety Device or Hazard
- Practical Approaches to Dementia Care
- Project Lifesaver International and Lo Jack Safety Net Solution
- Project Lifesaver Avonte's Law Blog
- Revised Algase Wandering Scale (RAWS)
- Short Geriatric Depression Scale (SGDS)
- The Cohen-Mansfield Agitation Inventory: Long Form with Expanded Descriptions of Behaviors
- The National Institute for Elopement Prevention and Resolutions
- The Windsor Star, Canada, Family sues long term care home over death, November 26th 2012
- US Department of Health and Human Services -Agency for Health Care Research and Quality -
National Guideline Clearinghouse - Wandering Guidelines and Assessments
- Vigil Dementia System Room Tour
- Vigil Health Solutions - Nurse Call and Dementia Monitoring Technology
- Wandering Behavior
- Wandering Committee Guidelines
- Wandering Behavior: Preparing for It and Preventing It.
- Wandering Protocol
Wandering and Elopement: Litigation Issues
Marie Boltz, MSN, APRN-BC, NHA
Director of Practice Initiatives
The John A Hartford Foundation Institute for Geriatric Nursing
NYU College of Nursing
One of the most challenging, life-threatening issues related to care of the person with cognitive loss is the occurrence of wandering, wherein the person strays into unsafe territories and may be harmed. The most dangerous form of wandering is elopement in which the confused person leaves an area and does not return. The risk of wandering has become a growing concern of families, long-term care facilities, regulators, and insurers.1 In addition to civil liability, care providers can be fined by the state regulatory agency for failure to prevent elopement.2 The effects upon the population served and the staff are no less dramatic. The sense of security of those served and their families is severely shaken, and staff morale as well as the organization’s reputation is dealt a devastating blow. 3 The aim of this chapter is to define wandering, elopement, and related issues, and to summarize the scope of the problems in terms of prevalence and effect. The types and causes of wandering and generally accepted approaches to care will be discussed. The regulatory and risk management considerations will also be presented. A hypothetical case will be presented. Finally, the role of an expert witness will be discussed.
The North American Nursing Diagnosis Association (NANDA) defines wandering as “ meandering, aimless, or repetitive locomotion that exposes the individual to harm; frequently incongruent with boundaries, limits, or obstacles.” 4 A common behavioral problem, wandering involves cognitive impairment that includes difficulty with abstract thinking, language, judgment, and spatial skills. 5 Wandering is also associated with disorientation and difficulty relating to the environment, and low social interaction, excessive pacing or increased motor activity. The person who wanders may also unknowingly trespass in another person’s nursing home room and an altercation may result. There are two types of wandering: goal-directed and non-goal directed. In goal-directed wandering, the person appears to be searching for someone or something. The person may also be looking for something to do and may make gestures as if performing a task. In contrast, in non-goal directed wandering, the person may wander aimlessly, and has a very short attention span. 6
A person who wanders is at risk for elopement, the act of leaving a safe area unsupervised and unnoticed and entering into harm’s way.7 Those who elope can be differentiated form those that only wander by their purposeful, overt, and usually repeated attempt to leave the building or premises. The person may go outside and experience hypothermia or other harmful conditions, including a traffic accident. Stairs are particular hazards, particularly for the eloping person who has poor balance, decreased strength, or poor vision.8
Individuals at risk for wandering include individuals with dementia, generally in the early to mid-stage. Dementia is defined by the Alzheimer’s disease and Related Disorders Association as “the loss of intellectual functions (such as thinking, remembering, and reasoning) of sufficient severity to interfere with the person’s daily functioning. Dementia is not a disease itself but rather a group of symptoms that may accompany certain diseases or conditions. Symptoms may also include changes in personality, mood and behavior. Dementia is irreversible when caused by disease or injury but may be reversible when caused by drugs, alcohol, hormone or vitamin imbalances, or depression.” 9 Alzheimer’s disease is the most common cause of dementia and is defined by the National Institute on Aging as “an irreversible progressive brain disorder that occurs gradually and results in memory loss, unusual behavior, personality changes, and a decline in thinking abilities.”10
It is estimated that fifty percent of all people over age eighty-five have Alzheimer’s dementia. Approximately half of all nursing home residents suffer from some form of dementia, most commonly Alzheimer’s disease. Wandering is most often associated with Alzheimer’s dementia, usually occurring two to four years after the onset of the disease. Statistics indicate that in the United States, more than 34,000 Alzheimer patients wander out of their homes or care facilities each year.11 Studies vary on the prevalence of wandering in institutionalized dementia patients, but is estimated that 11 % to 24 % wander.12
CAUSES OF WANDERING AND ELOPEMENT
Experts have identified factors that put individuals at risk for wandering and elopement. They include memory and recall deficits, poor visuo-spatial ability, disorientation, and expressive language deficits.13 Those who suffer from dementia experience the severe anxiety that is associated with not knowing where they are, what they are supposed to be doing, who the people are around them and perhaps not even their own name. Many institutionalized as well as community-dwelling persons, who experience this disorientation and memory loss, spend their time wandering in search of answers. Their fear is often compounded by the frustrating inability to express their feelings and needs, which provides further impetus to leave (elope) in search of a more secure and meaningful place. 14
Recent research also implicates changes in the visual cortex in one-third to one-half of all people with Alzheimer’s disease as contributing to the risk of becoming lost. This impairment leads to difficulty interpreting the three-dimensional structure of the environment, resulting in the inability to create a mental map. Thus the ability to keep track of where they have been is missing so they cannot retrace their steps back and become lost.15
In addition wandering is associated with a premorbid personality that is outgoing, altruistic, and sociable.16 There is evidence that pre-morbid lifestyle is likely to influence the predilection to wander. An active interest in music, physically and mentally, and a lifestyle that included activity in social and leisure activities are factors that increase the likelihood of wandering. 17 In comparison to other nursing home residents, residents who wander were found to have fewer physical diagnoses and were more likely to have experienced life-threatening situations or stressful events in the past. Also those who have historically responded to stress with psychomotor activity rather than emotional reactions are more prone to wander. 18
Researchers report that the physical environment contributes to the incidence of wandering. Pacing and wandering were found to occur when there was adequate lighting, low noise levels, and sufficient space to ambulate, suggesting that this type of movement provides a positive outlet for the person. 19 The use of neuroleptic medication can cause akathisia, which is a compulsion to be in motion, manifested by restlessness, pacing and occasionally wandering. 20
An emotional state that is frustrated, anxious, bored or depressed increases the predisposition to wandering. Sedating medication also increases the risk of wandering resulting from increased confusion. Finally, wandering may signal an unmet need, such as hunger, thirst, constipation, inactivity, need to use the toilet, fatigue, pain and environmental discomfort, such as uncomfortable seating, mattresses and lighting.21 When a person who does not have a history of cognitive loss begins to wander, this behavior may be a symptom of an undetected medical problem, such as an infection, circulatory problem, or metabolic condition whose only symptom is acute confusion.2
EFFECTS OF WANDERING
Effects upon the person
For some persons wandering is a positive behavior, fulfilling a need for exercise, sensory stimulation, or purposeful behavior. 23 In fact, findings suggest that residents in nursing homes who wander or pace in a safe environment experience better physical health and function. Furthermore, most residents tend to wander under optimal environmental and emotional conditions, unlike many other behaviors described as agitated which tend to occur when the person is experiencing discomfort. This use of wandering appears to be a positive adaptation that suggests that the person is continuing a lifelong pattern of exercise.24
Conversely, wandering can pose significant problems for the person who wanders as well as their families, direct caregivers, and care providers. There is a correlation between falls and wandering, related to fatigue, anxiety, and associated gait and balance instability.25 For the person who wanders, there are also safety challenges including the risk of:
- Entering an area that contains safety hazards including chemicals, fire hazards, tools and equipment that pose safety threats.
- Entering an area that is physically unsafe, especially stairwells, poorly lit areas, construction areas, etc.
- Entering an area that has a person who poses a threat to the person’s safety, including an irate or fearful fellow-nursing home resident, or another person who may exploit or otherwise harm the person who wanders.
- Getting lost and not being able to find the way back, and suffering from heat or cold exposure, drowning, or being struck by a car or other vehicle. The person may also incur dehydration and other medical complications resulting from not having needs met.
The above situations are associated with injury and at times, fatal results.26 It is estimated that dozens of cognitively impaired elderly people die annually as a result of wandering. 27
Effects upon the Person’s Family
For a family member caring for a person at home, wandering disrupts normal activities, sleep and health. The provision of respite services, including adult day care and/or home care, may provide relief when others share the responsibility for monitoring the person who wanders. However, oftentimes the burden becomes insurmountable and results in institutionalization.28 When the family elects to place a loved one in an assisted living or nursing home, they usually assume that their family member is now “safe”. This assumption is not often correct and needs to be addressed with clear information regarding the current risks as well as the plan to modify the risks. The wide range of emotions experienced by family members- relief, guilt, gratitude, and anxiety, make it difficult to provide honest information and collaborate to develop an effective plan to promote the safety of the person who wanders.
Effects upon the Facility
In a care provider setting, such as a nursing home, adult day care, and assisted living, the person who wanders requires much supervision, environmental modification, an individualized plan for communication approaches, exercise, and activities. 29 Staff require specialized training to meet the needs of persons with cognitive loss. In addition, attention must be given to the other persons who may be disturbed or frightened by the person who enters their room and unknowingly invades their privacy. Accidents involving residents negatively impact upon the facility’s ability to recruit prospective residents/patients as well as staff. The threat of liability looms large for the nursing home provider as hazardous wandering and elopements are among the most costly risk exposures in long-term care environments. 30
STANDARD APPROACHES FOR WANDERING
Goals for care-receivers who wander include promoting function and dignity and preventing injury. Assessment, identification of risk, individualized care planning, adequate staffing and environmental practices to promote safety, and immediate, emergency responses to resident elopement are the standard approaches to address these goals.31 These approaches are derived from evidence–based research and practice guidelines, and apply to all settings serving the older adult and persons with chronic physical and /or cognitive challenges. AssessmentThe first critical step in developing effective, individualized interventions is assessment, including an evaluation to determine the risk of elopement, and an assessment of the person’s wandering behavior. Evaluating for Elopement riskBecause most elopements occur shortly after admission, 32 potential residents should be screened prior to admission to determine their risk for unsafe wandering and elopement. A history of wandering /elopement as well as alterations in mental status are red flags that indicate high risk. The person should be screened for cognitive impairments, which include memory loss, decreased awareness, and disturbances in judgment, reasoning, and perception. Persons with cognitive impairments require further evaluation including a physical exam that identifies the type, degree and impact of the impairment. 33,34 The provider should also assess pre-morbid lifestyle to identify those likely to wander 35 and acquire information on the history of wandering and elopement- as perceived by the caregiver. The history should also include an evaluation of the degree of change in activity and routine associated with the wandering. The strategies, including environmental, used to date to deal with the wandering, (e.g. latches and alarms on doors, visual cues), as well as their effectiveness should be assessed.36Assessment also needs to rule out causes for restlessness, including the effects of
medication as well as medical problems, including diabetes, infection, and congestive heart failure which can aggravate cognitive impairments. 37 The clinicians should also assess for depression, which can mimic symptoms associated with dementia. 38 Finally, a functional assessment of communication ability, (receptive as well as expressive), hearing, gait, continence and nutritional status will identify factors that impact upon cognition as well determine the effect of impairment upon function.39Assessment of Wandering Behavior
The next key to promoting function and safety is to conduct a thorough assessment of wandering behaviors in order to determine the risk for injury and to develop an effective care plan. The term wandering needs clarification to determine if the person demonstrates: searching behavior, intrusion into other people’s rooms, pacing, attempts to exit the building, or straying into unsafe areas such as the closet that stores cleaning supplies. Associated behaviors including expressions of anxiety, loss, hunger, pain, incontinence, need for purposeful activity, and looking for someone or something, can all provide clues as to the unmet need of the person. Assessment of the typical time of day, path taken, and duration of the wandering should be noted to determine if there is a pattern.41, 42
IDENTIFICATION OF THOSE AT RISK
All residents and program participants with any history, past or present of wandering or confusion, especially those with elopement, should be identified so that can staff can be alert to their needs for support and supervision. Some facilities have persons who wander identified by wearing a colored bracelet or easily identifiable piece of clothing or jewelry.43 Another approach is to provide the staff, such as receptionists and security guards, with the names and photos of those who wander, as well as information on who to contact for assistance and how to redirect the person to a safe area. Staff in dietary, housekeeping, and maintenance should also be able to recognize those cared for who are at risk for unsafe wandering. Residents who are at risk for elopement should have identification on their person that identifies their name, the name/address of the facility, and that they are memory-challenged.
It is also recommended that the cognitively challenged person who resides in the community carry identification. The Alzheimer’s Disease and Related Disorders Association provides a national government-funded program that assists in the identification and safe return of individuals who have Alzheimer’s disease or a related dementia who wander from home, and become lost. The program includes: identification products, a national photo/information database, a 24-hour tool-free emergency crisis line, and education and training about wandering and other issues.44
The Care Plan
When a resident has been identified to be at risk for elopement or unsafe wandering, it is essential that the facility develop a plan of care. In the past, a common practice was to use physical and/or chemical restraints to prevent or curtail wandering. However, research demonstrates that restraints do not prevent injury, and both physical and chemical restraints often in fact, increase the risk of injury, physical decline, and depression, and can even cause death.45,46 Efforts to maintain function, promote safety, and compassionately assist residents to deal with the anxiety that manifests as “behavior problems” are the humane alternatives to restraints. Provision of an individualized care plan that addresses the person’s physical and psychosocial needs is the more humane and effective approach to wandering.The University of Iowa Gerontological Nursing Interventions Research Center has developed an evidence-based protocol to provide care plan guidelines for wandering, and these practices are grouped into the following main areas: environmental modifications, technology and safety, physical interventions, psychosocial interventions, and caregiving education.47
A multi-faceted approach to environmental modification is necessary to prevent injury and create a sense of well-being for the resident. Instead of preventing movement the environment should facilitate safe movement. The resident who wanders requires safe walking areas and lounge areas that provide an opportunity to stop and rest, to prevent falls/injuries from fatigue. The walking paths should be uncluttered, well lit, and lead to a fenced area or lounge. 48, 49 Using tape to create a grid-like pattern on the floor in front of exits or restricted areas decrease the risk of elopement. Because it gives an unstable appearance the grid lines act as a deterrent for exit-seeking behavior. 50
Wandering is often precipitated by sensory stimulation that is lacking, overwhelming, or meaningless. Decorating rooms with favorite pictures, art, etc. provide a sense of comfort and familiarity. The use of wall art, which may be tactile (three dimensional), and the presence of interesting artifacts create a positive distraction that may deter a person from wandering. 51 Camouflaging exits and assigning residents who wander with rooms located away from exits is another tactic.52 A combination of large-print signs in combination with portrait-like photographs assist in way finding for the resident who has trouble finding his/her room. 53
A basic and common safety intervention is the use of safety locks for closets and drawers that contain potentially hazardous materials. Many facilities employ locked or semi-locked doors to prevent the confused person from leaving the unit or facility where they are monitored. Semi-locked doors contain entry mechanisms that require cognitive skills that exceed those of most persons who wander. 54
Technology and safety
Electronic tagging is a system used to track residents who wander. The device may be a bracelet or may be a small lightweight device that is placed on a buckle, watch, or sewn into a piece of clothing. An alarm may sound when a resident exits a door or enters certain area. 55 The alarm may sound at the site or a distant site that is monitored. Video camera surveillance is another approach, albeit expensive. Door alarms are the most commonly used physical intervention, but can be unreliable due to staff not responding or turning the alarm off. Monitoring devices can assist the staff, however, they are not fail-proof and should not be used to replace careful supervision by staff. 56
Bed alarms are frequently used for the resident who leaves the bed at night to wander and/or is at risk for falls/injuries. The alarm is designed to alert the staff that the resident is out of bed and requires supervision and assistance. In order to prevent falls/injuries, and unsafe wandering the use of such alarms needs to be supplemented with an individualized plan to prevent nighttime injuries, including attention to comfort, toileting needs, safe bed height, use of nightlights, following the person’s routine, and supervision.57
Physical and Psychosocial interventions
The psychosocial and physical interventions described in the literature are concerned with assessing and treating depression and physical problems, and providing meaningful activity. These approaches need to be clearly defined in the care plan. Sufficient support and supervision from staff is essential to adequately provide these interventions.
Depression can adversely affect cognition and function, yet it is one of the most overlooked clinical problems in the nursing home. 58 Residents with cognitive loss should be routinely assessed for depression. Wandering can develop more in depressed Alzheimer’s disease patients, and the care plan needs to address psychosocial and pharmacologic interventions. The plan also needs to include the management of chronic medical conditions that can alter cognition.
Activities are an essential component of the care plan for the resident who wanders. The traditional nursing home bingo game is not adapted to the needs of the person who has memory loss, anxiety, restlessness, and limited attention span. A structured activity plan provides consistent supervision and allays the anxiety that is associated with memory loss and disorientation by answering the question, “What should I be doing?” The resident who is provided with positive activity does not have to wander to search for meaningful stimuli.59 Activities should also provide exercise including walking programs that provide physical outlets. 60 Group activities that relieve tension and provide stimulation and exercise are dancing, cooking, flower arranging, and active games. 61 Activities that increase self-esteem and engage the resident are useful endeavors such as watering plants, folding linen, gardening, and setting tables. The resident who wanders at night can be included in rounds with staff, fold clothes, and making a snack. Successful activity plans provide a great deal of consistent routine, task segmentation, (wherein tasks are broken down into small steps to be accomplished) and exercise. The result is decreased anxiety, increased function, and fewer predilections to aimlessly wander.62
Communication that is adapted to the person’s memory challenges, and demonstrates an understanding of the person’s history, preferences, routines, and values, promotes the person’s sense of security. The person who feels understood and has a sense of being in the right place is a less likely to wander, searching for the place he/she belongs.63, 64
Consistent staff schedules are important to provide residents a sense of security and also to provide follow-through of the care plan. The staff member assigned should frequently observe the whereabouts of at-risk persons and when the person attends appointments, such as Physical Therapy, the responsibility for supervision must be formally handed over to another. Adequate supervision of residents at risk for elopement and unsafe wandering is essential, on all three shifts. The traditional practice of staffing the night shift at the minimum level is a particularly unsafe approach for mobile residents who have cognitive loss. 65
The specialized needs of patients with cognitive loss require staff and family caregivers cognizant of their needs for adapted communication, provision of activities, environmental modification, and safety needs.66 Staff also requires education and competency evaluations addressing facility policy for assessment, equipment use, and the retrieval system for a missing person. In facilities, receptionists and security guards need education on how to redirect residents who are attempting to unsafely leave, and the provision of photo identification of at-risk residents supports monitoring their whereabouts.
The cognitively impaired person’s plan of care needs to include guidelines that initiate reassessment. Behavior logs that monitor the degree and type of behavior need to be utilized to monitor the effectiveness of the care plan. Revising the care plan is a standard process that ensures that the provider responds effectively to the ever-changing needs of the person. In addition, those persons not initially identified as an elopement risk may develop cognitive impairments that require interventions to prevent elopement. Thus, providers serving the elderly are expected to be vigilant in their assessment for the mental status changes and attendant behavior changes that are common in the elderly.
In addition to the above-stated, interventions, some nursing homes and assisted living facilities provide designated units, often called “Special Care Units” that segregate residents with dementia and/or behavioral challenges from other residents. Some of these units have decreased elopements by providing a physical plant that promotes safe, supervised mobility, increased staffing, specialized training for staff, and activities that are adapted to the needs of persons with cognitive challenges.67 The over-all effectiveness of these units, in terms of improving clinical outcomes related to function, has not yet been established. 68
Response to an elopement
When a resident elopes, time is of the essence as mortality rates and injuries for those who elope rise dramatically after 24 hours. The care provider is expected to notify the local police to facilitate a search and retrieval effort. An organized search by staff should include periodic re-check of the area where the person was last seen. These missing persons are often found within a mile of where they were last seen. Familiar places, including former job sites should be checked. The media should be notified if: the person has not been located after two hours, or the person has a life-threatening illness, or if weather conditions are severe.69 The state regulatory agency should also be notified, and provided a report on the incident as well as the provider’s plan to prevent reoccurrence.
Nursing facilities must comply with federal regulations administered by the Center for Medicare and Medicaid Services (CMS). Long-term care facilities must also comply with state health regulations and life-safety codes, as well as local fire and safety regulations. Local and state statutes mandate the maintenance of the building in a safe manner.
These federal regulations 70 are the most pertinent to the daily operations of the facility, including the management of wandering and elopement. Quality of care requirements are the most far-reaching of the federal regulations, requiring that residents receive care and services to “attain or maintain the highest physical, mental, and psychosocial well being of each resident in accordance with a written plan of care.” 42 U.S.C.Sec.1396r (b)(2). This directive holds the facility accountable not only to protect the resident from injury, but also to promote health and function.
The following federal regulations are relevant to the clinical issue of wandering and elopement: assessment and care planning, accidents, accommodation of needs, environment, and equipment, use of restraints, and abuse and neglect.
The regulation that governs assessment and care planning, F Tag 272, states “The facility must make a comprehensive assessment of a resident’s needs which…describes the resident’s capability to perform daily life functions and significant impairments in functional capacity.” The associated surveyor guideline 483.20(b)(1)(2) states that the facility is responsible for addressing all needs and strengths of residents, from the time of admission. Furthermore, F Tag 281 and 282 dictate that the services provided or arranged by the facility “must meet professional standards of quality” and “be provided by persons in accordance with each person’s written plan of care.” In evaluating compliance with this regulation for the care of a resident who wandered or eloped, the surveyor would determine if the facility:
- assessed adequately for risk;
- developed an interdisciplinary plan of care to promote both safety and function, consistent with the professional standards of quality, i.e. addressed the resident’s needs for exercise, management of psychiatric and medical problems, and promotion of comfort and emotional wellbeing; and
- evaluated the care plan and revised it if it was ineffective or if the needs of the resident changed.
The use of restraints to control wandering or elopement is addressed clearly by the regulations. F Tag 221 and 222, respectively, state that the resident has the right to be free from any physical or chemical restraint that is imposed for purposes of convenience, and is not required to treat the resident’s medical symptoms. The surveyor guidelines, 483.13(a) describe the need to assess residents for alternatives to restraints, including meaningful activities, manipulation of the environment and the provision of restorative care, i.e. measures to promote mobility, continence, and self-care.
The philosophical underpinning of the federal regulations, i.e., support of resident rights, including autonomy and self-direction, require that the nursing home accommodate resident needs, instead of the facility requiring that the resident adhere to the convenience-driven, institutionalized practices of the past. Nursing homes are expected to have the resources, human and material, to meet the needs of those served. The regulation titled, “accommodation of needs,” (F Tag 246) states “ A resident has the right to reside and receive services in the facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.” Surveyor guideline 483.15(e)(1) requires that the facility adapt the environment to “enable residents with dementia to walk freely”. Thus the standard dictates that the facility provides accommodation for safe walking. In addition, the facility must provide for the resident’s safety. The regulation for “accidents” (F Tag 323) requires that the facility must ensure that the resident environment remain as free of accident hazards as is possible and F Tag 324 states that “Each resident receives adequate supervision and assistive devices to prevent accidents.” Furthermore, surveyor guideline 483.25(h)(2) requires that the facility “identify each resident at risk for accidents and/or falls, and adequately plans care and implements procedures to prevent accidents.” An incident must also be reviewed and a plan developed to prevent reoccurrence. This plan must be incorporated into the resident’s overall care plan.
The facility must maintain a system to ensure that equipment such as alarms, tracking devices, and monitors are periodically checked and maintained for adequate functioning. The regulation labeled, “accidents” (F Tag 323) and “ space and equipment” (F Tag 456) states that, “The facility must maintain all essential mechanical, electrical, and patient care equipment in safe operating condition.”
The regulations recognize that residents with cognitive loss require activities that address their needs for exercise, socialization, self-expression, purpose, and leisure. They further require that the facility adapt the activities to the resident’s impairment, i.e., modify the approach so that the person with decreased attention span, language difficulty, and memory impairment can participate fully. This requirement is evident in the regulation for activities (F Tag 248) that state, "The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.” Surveyor guideline, 483.15(f)(1) requires that the activities program provide” stimulation or solace; promote physical, cognitive, and/or emotional health; enhance, to the extent practicable, each resident’s physical and mental status; and promote each resident’s self-respect by providing, for example, activities that support self-expression and choice.”
In summary, the professional standards for wandering and elopement described in the literature that include the need for assessment, individualized care plan, environmental modification, and physical/psychosocial interventions, are mirrored by the federal regulations for nursing homes.
Assisted living, home health and hospice agencies, and adult day care facilities are regulated only at the state level. The details of regulations vary from state to state, and largely are not as specific as the federal regulations for nursing homes. However the staff who practice in these settings are required to function under the generally accepted standards of care which include providing adequate supervision and care to those served, educating caregivers as indicated, maintaining a safe environment, and providing or securing services that meet their needs. Those organizations that market services to the family of the person with dementia are particularly held accountable to the standards that are derived from research, described in professional literature, and recommended by recognized expert organizations, including the Alzheimer Disease and Related Disorder Association.
Legal Risk Management Strategies
As of August 2002, the average cost of an elopement claim had doubled in the past five years to nearly $215,000 per claim. Recently a jury in Florida awarded six million dollars in a suit against a facility that allegedly was aware of a resident’s tendency to wander bur failed to protect her. A Louisiana jury awarded a widow $200,000 after her husband eloped from a facility and was struck by a vehicle. 71
Care providers minimize the risk of injury due to wandering and elopement through a combination of the following management tools: policy and procedure, staff training, and quality assurance/improvement activity.
Policy and Procedure
The Admission policy needs to describe the criteria for admission/discharge, and include the process by which a person, whose needs cannot be met, would be discharged. Marketing material should be consistent with the provider’s policy and ability to keep the promises described in brochures and the promotional material. For example, a pledge that the person will “age in place” in an assisted living facility that can not safety meet the person’s needs may be a promise that can not be fulfilled. The facility should describe its commitment to promoting the safety of those served, consistent with quality standards, and define how this is accomplished, as opposed to describing a commitment to providing “absolute safety”, a goal that may be unreasonable, and that lends itself to vague interpretations of how the goal will be met.
The person with dementia is particularly vulnerable to abuse and neglect. Policy and procedure needs to clearly examples of mistreatment, prevention approaches, method of investigation, treatment of those potentially abused, and reporting mechanisms. All accidents, including those related to elopement should be evaluated for potential failure to prevent abuse/neglect. Other rights, including the right to be free from unnecessary restraint should be also be addressed in facility policy.
A policy and procedure addressing assessment and care planning is necessary to support the safety of residents who wander including guidelines for assessing risk, assessing resident need associated with behaviors, developing an individualized plan, reassessing and evaluating the care plan’s effectiveness, and revising the plan as needed. Because cognitively challenged residents are usually unable to remember and/or articulate their needs, a method for communicating the care plan, including anticipating needs, to all staff on all three shifts is crucial.
Safety policies should clearly define the safeguards that the facility employs to prevent accidents and elopements. A process of reviewing incidents such as falls, accidents, altercations, and elopements is a standard policy that provides the administration and staff an opportunity to determine the outcome of an incident, the cause or factors related to the incident, and develop a plan to prevent reoccurrence. Finally, the facility needs a plan to locate a missing resident, mandated by the federal regulations to be in the nursing home’s disaster and emergency preparedness plan. The Joint Commission Accreditation of Healthcare Organizations (jcaho), which provides voluntary accreditation for nursing homes, considers a resident elopement a sentinel event, requiring a root cause analysis, with the results to be reported to JCAHO. This process needs to be described in policy, with the accountability described in the procedure. 72
Clinical Policies should reflect clinical practice guidelines, including the use of alternatives to chemical and physical restraints. Environmental policies/procedures need to address equipment management including the safety checks and maintenance of alarms, and other resident equipment.
The care of older adults with cognitive loss requires staff that is knowledgeable and skilled in the specialized assessment, psychosocial interventions, communication approaches and activity needs of those served. 73 When staff is unable to demonstrate the ability to competently respond to the needs of persons with dementia, the results can be catastrophic, including increased anxiety, elopement, accidents, and injury. Staff education, then, should focus on enabling staff to understand the effects of cognitive loss upon the person’s emotional state, function, and physical health. If this understanding is acquired then staff will appropriately perceive wandering as a coping mechanism that requires safe expression rather than a negative behavior that requires restraint. Professional staffs need to be educated to the clinical presentation of dementia, and the physical and psychiatric problems that can both mimic and co-exist with its presentation. Care interventions including communication techniques, meaningful activities, incontinence management, nutritional support, modification of the environment, promotion of exercise, and management of acute and chronic health problems are standard topics found in a training program for staff caring for persons with dementia.
Information and skill validation of care needs to be augmented with an understanding of the facility’s polices and procedures that support meeting those needs. Staff need initial and ongoing training on the policies that address the rights of those served, prevention and detection of abuse and neglect, the risk identification system, assessment and care planning processes, clinical practice guidelines, the safe use/maintenance of equipment, emergency procedures including the response to elopement, and the use of chemical and physical restraints.
Quality Assurance/ Improvement activity
Even the small facility needs a process to measure the effectiveness of care provided. Basic quality assurance activity 74 includes:
- Evaluation of each incident report to evaluate the care provided to individuals and make immediate revisions as necessary in the plan. All elopements should be evaluated immediately, and a plan developed to prevent reoccurrence.
- Evaluation of all incident reports, over a certain time period, on a consistent basis, trends to identify areas that need improvement. This analysis also needs to identify practices that engender mistreatment or safety hazards, and development of a plan to prevent or correct deficiencies.
- Environmental rounds, conducted periodically, to assess and maintain the safety and operability of the physical plant and equipment
- Staff training records to evaluate compliance with facility and industry standards
- Tracking and analysis of clinical outcomes, such as falls/accidents and restraint use
- Staffing hours, compared to the prescribed staffing pattern
- Observation rounds to evaluate staff performance and follow-through on facility policy and implementation of program plans
- Evaluation of the facility’s compliance with supporting resident/patient rights, including the right to free from restraint.
To be successful the provider’s approach to quality assurance/improvement needs
to be interdisciplinary, measure outcomes (e.g. number of accident and elopement), and measure degree of compliance (e.g. extent to which risk assessments are completed). Quality improvement employs a problem-solving cycle, that is, analyzes the factors that contribute to areas of noncompliance or weakness, develop an action plan to positively modify these factors study the results, and revise the plan as needed. This critical management tool is particularly necessary when dealing with the clinical issue of wandering and elopement, which pose potential threats to the lives of those served.
BG was a seventy-old man admitted to the nursing home, from home because he was newly incontinent, and awakened at night, frequently attempting to leave the house and “go to work” per his daughter. His admitting diagnoses included senile dementia - probable Alzheimer type, and mild hypertension. Upon admission, the admitting nurse identified as being high risk for wandering/elopement because due to his history of wandering and history of dementia. His initial care plan included:
(His daughter and staff determined that he usually wandered when he was
- Supervision checks to be performed every fifteen minutes by his assigned caregiver. (The nursing assistant would walk with him to an activity then “hand over” the responsibility to monitor his whereabouts to the assigned activity staff.)
- A plan for consistent caregivers
- A screening for depression was conducted and was not remarkable for depression. Also, Benadryl, which was used at home for sleep, was discontinued due to its high side-effect profile in the elderly, including the side effect of increased confusion. His medical work-up was negative.
- Communication techniques that included physical cueing, validation of emotions. There was also a plan to redirect him away form the semi-locked door by saying, “I was looking for you. We need to go this way.” Then he was to be asked to complete one of several projects set up by the activity staff.
looking for work.)
- Mapping out a routine that described his normal time for awakening, meals and bedtime, combined with a toileting program and structured activities. His activities included a walking program, in the morning, afternoon, and evening, and lifestyle activities including yard work, woodworking, music appreciation, dance class.
- The siderails on his bed were removed to prevent the possibility of falls/injuries at night due to climbing over the rails. A toileting program was also provided at night, at bedtime and at 5 AM, his usual times to awaken.
- When staff noted that he attempted to leave with departing staff at change of shift time, (3 PM) his walking time was changed to coincide with this time.
- The receptionist and security guard were provided with his name, photo, a brief social history, and techniques to redirect him. This information was also shared with the housekeepers, dietary, and maintenance staff on the unit.
One afternoon, a visitor who recognized him engaged in conversation, and
assisted him inadvertently to leave the facility. Fifteen minutes later the nursing assistant found him in the driveway. He had apparently tripped and fell, sustaining bruise on his arm. He was limping also. The nurse assessed him and notified the doctor and family of the incident. He was transported to the emergency room to have his hip evaluated. After it was determined that he had no injury, he was transported back to the facility. He demonstrated normal vital signs and no physical or behavioral changes upon his return.
Upon his return the facility revised his care plan to include the provision of direct visual oversight during waking hours, and nighttime checks every fifteen minutes. The next day he was found unresponsive, having sustained a massive myocardial infarction, diagnosed in the emergency room, where his cardiac enzymes confirmed the diagnosis of the ER doctor.
BG’S daughter brought suit against the facility, stating that his wandering and elopement, and subsequent fall resulted in his death. The plaintiff expert however, upon reviewing relevant documents, stated that the facility had adequately identified and addressed his risk factors, revised his plan as needed, and provided adequate supervision. She based this opinion upon a review of the medical record, the staffing schedules the day of the fall and two weeks prior, the facility polices and procedures, the quality assurance records describing the facilitiy’s activity reviewing and responding to falls/accidents, the equipment check for the semi-locked door (last checked the day before the incident), and the incident report. She also opined that the cause of death could not be attributed to his wandering and fall. The case was settled with an award of $10,000 to the surviving daughter.
THE EXPERT WITNESS ROLE
The expert witness for a legal case involving wandering or elopement should have:
The expert witness will most likely evaluate a dramatic, sentinel incident, but should also offer an opinion on the care antecedent to the event, and the facility’s immediate and follow-up response.
- Experience and training caring for person with cognitive loss and the age group of the involved person;
- Clinical assessment skills related to cognitive loss, associated with a professional license in advanced nursing;
- Experience in the relevant (or related) setting;
- Knowledge of the relevant regulations and management systems
The expert witness answers the following questions:
- Was care provided consistent with generally accepted standards?
- Did the staff adequately assess the person?
- Was the person chemically or physically retrained? If so what was the effect?
- Was the physician and responsible party informed appropriately of changes in condition?
- Was there enough staff on duty to properly meet the person’s needs?
- Was the staff properly trained to supervise and care for the resident?
- Did the facility employ devices to prevent elopement and/or harmful wandering?
- Did staff properly respond to the alarm?
- Was staff adequately supervised?
- Was the unsafe wandering and/or elopement reported to the police and regulators as required?
- Did the person have a history of unsafe wandering/? How adequately did the facility respond?
- Did the facility inspect and maintain safety equipment?
- Does policy and procedure address: admission criteria, safety needs, abuse and neglect, use of relevant equipment and environmental modification, supervision of staff, and response to unsafe wandering/elopement?
- Did the administration evaluate all incidents, including this one? Is there a pattern of unsafe wandering and/or elopements? How has the facility responded?
To conduct an expert review the expert witness requires a copy of the following:
- The medical /service record
- The admission agreement and administrative record
- The facility brochure
- All policy and procedures
- Facility organizational chart
- Projected staffing pattern
- Staffing schedules (actualized)
- Assignment sheet for the involved date
- Staff training records, (content and attendance)
- All incident reports for the involved person
- Manufacturers instructions for equipment use
- Equipment management logs,
- Quality assurance plan and records,
- Survey results.
Injury or death due to unsafe wandering and/or elopement is a tragedy that requires an incisive evaluation to determine the merits as well as potential culpability of the care provider. The expected outcome of care and services is both prevention of harm as well as maximum function and dignity. The standards of care are very clear: assess risk, identify and respond to risk, assess related needs, provide care to meet needs while promoting health and safety, and evaluate the plan and revise as needed. Facilities may provide such care, consistent with standards and still have less than desirable effects. The role of the litigative and clinical team is to make that determination using their combined expertise and experience as well as understanding of the specialized needs of the cognitively challenged older adult.
1 DL Algase, A Century of Progress: Today’s Strategies for Responding to Wandering Behavior, 18 Journal of Gerontological Nursing. 28-34 (1992)
2 T Algier, How Communication Technology Reduces Risk, 11 NURSING HOMES LONG –TERM CARE MANAGEMENT. (2002).
4 NANDA, Nursing Diagnosis: Definitions and Classifications, 2001-2002, nanda, Philadelphia, PA, 206-207 (2001).
5 DL Algase, A Century of Progress: Today’s Strategies for Responding to Wandering Behavior, 18 Journal of Gerontological Nursing. 11, 28-34 (1992).
6. B Roberts and DL Algase, Victims of Alzheimer’s Disease and the Environment, 23 Nursing Clinics of North America. 83- 93 (1988).
7 L. Moishita, Wandering Behavior in Alzheimer’s Disease: Treatment and Long-Term Management, 157-176 (J.L. Cummings & BL Miller, eds.1990).
8 W Coltharp, M Ritchie, & M Kass, Wandering, 22 Journal of Gerontological Nursing. 5-10 (1996).
10 National Institute in Aging Progress Report on Alzheimer’s Disease, Washington, DC; U.S. Department of Health and Human Services, Public Health Services, National Institute of Health NIH Publication No. 99-3636. (1998).
11 ML Warner, Missing: What to do About Wandering, ADVICE & ADVANCES
12 NM Silverstein, Why Long-Term Care Facilities Should Be Concerned About Wandering Behavior, ADVICE & ADVANCES
14 Rader, A Comprehensive Staff Approach to Problem Wandering, 28 The Gerontologist. 756-760 (1987).
15 KH Namazi, TT Rosner, & L Rechlin, Long-term Memory Cueing to Reduce Visuo-spatial Disorientation in Alzheimer’s Disease Patients in Special Care Unit, 7Journal of Alzheimer’s Care and Related Disorders & Research.10-15 (1991).
16 DW Thomas, Understanding the Wandering Patient: a Continuity of Personality Perspective, 23 Journal of Gerontological Nursing. 16-24 (1997).
17 DW Thomas, Evaluating the Relationship Between the Premorbid Leisure Preferences and Wandering among Patients with Dementia, 23 ACTIVITIES, ADAPTATION AND AGING. 33-48 (1999).
18 J Cohen- Mansfield, P Marx, & L Freedman, Two Studies of Pacing in the Nursing Home, 46 Journal of Gerontology: Medical Sciences. M77-M83 (1991).
19. J Cohen-Mansfield & P Werner, Environmental Influences on Agitation: An Integrative Summary of an Observational Study, American Journal of Alzheimer Disease and Related Disorders. 32-39 (January/February 1995).
20 AJ Gelenberg & MD Katz, Antipsychotic Agents. In Geriatric Pharmacology 375-408 New York: McGraw-Hill (R Bressler & MD Katz, eds 1993).
21 GR Hall, Research- Based Protocol: Alzheimer’s Disease and Chronic Dementing Illnesses, The University of Iowa Gerontological Nursing Interventions Research Center 25 (M Titler, ed. 1997).
22.Robert L. Kane, Joseph G. Ouslander, & Itamar B. Abrass, Essentials of Clinical Geriatrics. 129-134 New York: McGraw-Hill (1999).
23. DL Algase, C Beck, A Kolanowski, et al, Need-driven Dementia- Compromised Behavior: An Alternative View of Disruptive Behavior. 14 American Journal of Alzheimer’s Disease. 10-19 (1996).
24 J Cohen-Mansfield, P Werner, W Culpepper, M Wolfson, & E Bickel, Wandering and Aggression in The Practical Handbook of ClinicalGerontology 379 (L Carstensen, B Edelstein, & L Dornbrand, eds.1996).
25 J Cohen- Mansfield, P Marx, & L Freedman, Two Studies of Pacing in the Nursing Home, 46 Journal of Gerontology: Medical Sciences. M 77-M 83 (1991).
26 DL Algase, Wandering: A Dementia-Compromised Behavior, 25 JOURNAL OF GERONTOLOGICAL NURSING. 10-13 (1999).
27 T Algier, How Communication Technology Reduces Risk, 11 NURSING HOMES LONG –TERM CARE MANAGEMENT. (2002).
28 GS Moak, Characteristics of Demented and Nondemented Geriatric Admissions on a State Hospital, 41 Hospital and Community Psychiatry, 799-801 (1990).
29 J Rader, A Comprehensive Staff Approach to Problem Wandering, 27 The Gerontologist. 756-760 (1987).Scott Kopetz, Cynthia D. Steele, Jason Brandt, Alva Baker, Marcie Kronberg, Elizabeth Galik, Martin Steinberg, Andrew Warren and Constantine G. Lyketsos. Characteristics and outcomes of dementia residents in an assisted living facility. INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY 15, 586-593 (2000).
30 L Mustard, Negligence in Post-Hospital Care, CQ, The Journal of Cost and Quality
31 Michigan Department of Consumer & Industry Services, Bureau of Health Systems, Prevention of Wandering: From Long-Term care Facilities, February 2002 website
32 Praeventus- Addressing Resident Wandering and Elopement Issues
33 M Folstein, M Folstein, & P McHugh, Mini- mental state exam: A Practical Guide for Grading the Cognitive State of Patients for Clinicians, 12 Journal of Psychiatric Research. 189 (1975).
34 DL Algase, E Beattie, E Bogue, & L Yao, The Algase Wandering Scale: Initial Psychometrics of a New Caregiver Reporting Tool, 16 American Journal of Alzheimer’s Disease and Dementia. 141-152 (2001).
35 J Peafield, M Futrell, & C Cox, Wandering: An Integrative Review, 28 Journal of Gerontological Nursing. 44-50 (2002)
36 M Futrell & M Titler, Evidence –Based Protocol: Wandering, The University of Iowa Gerontological Nursing Interventions Research Center. 6 (M Titler, ed. March 2002).
37 MF Folstein, Differential Diagnosis of Dementia: The Clinical Process, 20Geriatric Psychiatry. 45-57 (1997).
38 CG Lyketsos, C Steele, L Baker, et al, Major and Minor Depression in Alzheimer’s Disease: Prevalence and Impact. 9 Journal of Neuropsychiatry and Clinical Neurosciences. 556-561 (1997)
39 RG Lodgson, L Teri, SM McCurry et al, Wandering: A Significant Problem Among Community Residing Individuals With Alzheimer’s Disease, 53 B Journal of Gerontology: Psychological Sciences. 556-561 (1997).
41D Martino-Saltman, BB Blasch, RD Morris, & LW McNeal, Travel Behavior of Nursing Home Residents Perceived as Wanderers and Nonwanderers, 31THE GERONTOLOGIST. 666-672 (1991)
42 MA Matteson & A Linton, Wandering Behaviors in Institutionalized Persons with Dementia, 22 Journal of Gerontogical Nursing. 39-46 (1996).
43 J Gaffney, Toward a Less Restrictive Environment, 7 Geriatric Nursing. 94-95 (1986)44 Safe Return, Alzheimer Association
45 NE Strumpf & N. Tomes Restraining the Troublesome Patient: A Historical Perspective on a Contemporary Debate. 1Nursing Historical Review. 3-24 (1993).
46 SH Miles SH & PI Irvine, Deaths Caused by Physical Restraints, 32 Gerontologist. 762-762 (1992).
47 M Futrell & M Titler, Evidence –Based Protocol: Wandering, The University of Iowa Gerontological Nursing Interventions Research Center. 6 (M Titler, ed. March 2002).
48 R Allen-Burge, AB Stevens, & LD Burgio, Effective Behavioral Interventions FOR Decreasing Dementia-related Challenging Behavior in Nursing Homes, 15 International Journal of Geriatric Psychiatry. 213-232 (1999).
49 R McGrowder-Lin & A Bhatt, A Wanderer’s Lounge Program for Nursing Home Residents with Alzheimer’s Disease, 28THE GERONTOLOGIST. 607-609 (1988).
50 DA Forbes, Strategies for Managing Behavioral Symptomatology Associated with Dementia of the Alzheimer Type: A Systematic Overview, 30 Canadian Journal of Nursing RESEARCH. 67-86 (1998).
51ji dickenson & J McLain –Kark, Wandering Behavior and Attempted Exits Among Residents Diagnosed With dementia –Related Illness: A Qualitative Approach, 10 Journal of Women and Aging. 23-34 (1998).
52 LN Gitlin & MA Corcoran, Managing Dementia at Home: The Role of Environmental Modifications, 12 TOPICS IN GERIATRIC REHABILITATION. 28-39 (1996).
53 B Nolan, R Matthews, & M Harrison, Using External Memory Aids to Increase Room Finding by Older Adults with Dementia, 16 AMERICAN JOURNAL OF ALZHEIMER’S DISEASE. 251-254 (2001).
54 JP Butler & CA Barnett, Window of Wandering, 12 Geriatric Nursing. 226-227 (1991).
55 R McShane, K Gedling, B Kenward, et al, The Feasibility of Electronic Tracking Devices in Dementia: a Telephone Survey and Case Series, 13 International Journal of Geriatric Psychiatry. 556-563 (1998).
56 KD Mellilo & M Futrell, Wandering and Technology Devices: Helping Caregivers Ensure the Safety of Confused Older Adults, 24 Journal of GERONTOLOGICAL NURSING. 32-38 (1998).
57 E Capezuti, Preventing Falls and Injuries While Reducing Siderail Use, 8 Annals of Long-Term Care. 57-63 (2000).
58 BW Rovner, CD Steele, Y Shumuley, & MF Folstein, A Randomized Trial of Dementia Care in Nursing Homes, 44 Journal of the American Geriatric Society. 7-13 (1996).
59 ML Fitzgerald-Cloutier, The Use of Music Therapy to Decrease Wandering: An Alternative to Restraints, 11 Music Therapy Perspectives. 32-36 (1993).
60 SK Holmberg, A Walking Program for Wanderers: Volunteer Training and Development of an Evening Walker’s Group, 18 Geriatric Nursing. 160-165 (1997)
61 GR Hall & D Laloudakis, A Behavioral Approach to Alzheimer’s Disease: The Progressively Lowered Threshold Model, 7 Advance for Nurse Practitioners. 39-46 (1999)62 SK Holmberg, Evaluation of a Clinical Intervention for Wanderers on a Geriatric Nursing Unit, 11 Archives of Geriatric Nursing. 21-28 (1997).
63 N Monsour & SS Robb, Wandering Behavior Old Age: A Psychosocial Study, 27 SOCIAL WORK. 411-416 (1982).
64 JM Richter, KA Roberto & DJ Bottenberg, Communicating with Persons with Alzheimer’s Disease; Experiences of Family and Formal Caregivers, 9 archives of psychiatric nursing. 279-285 (1995).
65 Barbara Bowers & M. Becker, Nurse’s Aides in Nursing Homes: The Relationship between Organization and Quality. 3:The Gerontologist (1992).
66 Diane Brannon & M.A. Smyer, Good Work and Good Care In Nursing Homes. 18: GENERATIONS. 3 (1994)
67 M Mass, G Hall, J Specht & K Buckwalter, Dedicated, Not Isolated: Development of Long Term Care Alzheimer’s Units. In Geriatric Mental Health: Current and Future Challenges (Buckwalter, K, ed 1992).
68 CD Phillips, PD Sloane, & C Hawes, et al, Effects of Residence in Alzheimer Disease Special Care Units on Functional Outcomes, 278 JOURNAL OF THE AMERICAN GERIATRIC SOCIETY1340-1344 (1997).Scott Kopetz, Cynthia D. Steele, Jason Brandt, Alva Baker, Marcie Kronberg, Elizabeth Galik, Martin Steinberg, Andrew Warren and Constantine G. Lyketsos. Characteristics and outcomes of dementia residents in an assisted living facility. INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY 15, 586-593 (2000).
69 G Flaherty, Involving Police When Memory-Impaired Elders Are Missing, ADVICE ADVANCES
70 Federal Regulations 42 CFR 483, Center for Medicare and Medicaid (CMS) website
71 T Algier, How Communication Technology Reduces Risk, 11 NURSING HOMES LONG –TERM CARE MANAGEMENT. (2002).
72 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Quality Improvement in Long Term Care. 68 (2000)
73 ECRI, Preventing Abuse and Neglect. 1 Continuing Care Risk Management, Risk Analysis. 1-16 (1994)74 M Trellis -Nayak & G Snyderman, Quality Improvement: The View from JCAHO, Nursing Homes. 2002 (Sept/ Oct 1992).