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Elopement Guidelines for Assisted Living Facilities

PDF Version of DQA 10-009  (PDF, 48 KB)

Date: April 27, 2010 -- Original Release date
May 20, 2010 -- Re-issued date
DQA Memo 10-009
To: Adult Family Homes AFH 04
Community Based Residential Facilities CBRF 05
Residential Care Apartment Complexes RCAC 04
From: Kevin Coughlin, Director
Bureau of Assisted Living

Otis Woods, Administrator
Division of Quality Assurance

Elopement Guidelines for Assisted Living Facilities


The purpose of this memo is to remind assisted living providers of the dangers that exist when persons with confusion or dementia wander away from assisted living facilities and to assist providers in the development of a preventative plan related to elopement.

Persons with confusion or dementia who elope from facilities are at great risk of harm. Residents may become lost; be exposed to extreme heat, cold, or other inclement weather; enter traffic, bodies of water, or wooded areas; and be vulnerable to many other hazards, such as uneven pavement which increases risk of falls. Bureau of Assisted Living (BAL) data for the calendar year 2009 indicates that there has been a 38% increase in the number of reported elopements from assisted living facilities since 2006.

Case Histories

The 2009 BAL Serious Violations with Enforcement Report includes nine incidents of elopement that resulted in enforcement, including:

  • A CBRF did not provide adequate supervision for a resident with dementia and a history of wandering. The resident left the building without staff being aware and fell outdoors, sustaining contusions to the face and knees. The resident was hospitalized with an intraventricular hemorrhage, was discharged to a nursing home, and died from the injuries.
  • In a CBRF, residents who required supervision, including a resident with a walker, eloped from the facility on several occasions and were returned by neighbors or police. Residents left the facility, for example, when caregivers were in the garage smoking cigarettes. The facility did not document the incidents or address the safety risks.

Provider Responsibility for Identifying Persons at Risk for Elopement

Assisted living providers are responsible for completing a thorough assessment of all residents to identify individuals who are at risk for elopement or have a history of elopement. The ongoing comprehensive assessment must identify conditions that put the resident at risk for elopement, such as confusion, dementia, cognitive impairment, or judgment impairment.

Provider Responsibility for Identifying Factors that Contribute to Potential for Elopement

Providers must evaluate factors or triggers that contribute to the potential for elopement for those residents determined to be at risk and residents who have had incidents of elopement. Factors or triggers may include: time of day when the resident is most restless; level of activity; resident comfort or discomfort; adequacy of staffing patterns; degree of staff interaction with residents; level of staff supervision; and physical factors such as hydration, nutrition, hunger, constipation, or loneliness.

Provider Responsibility in the Prevention of Elopement

Assisted living providers are responsible for protecting residents at risk for elopement. All staff must be aware of the dangers of elopement, know the risk factors and triggers, and know which residents are at risk. Facility policies and procedures must include a plan for the prevention of elopement. Staff must be adequately trained in the preventative plan which could include the following elements:

  • Staff must frequently observe the location of each resident at risk for elopement. Ongoing communication between staff is necessary to transfer information related to the presence of factors that indicate elopement is likely.
  • All facility staff must be able to recognize residents at risk and be prepared to intervene. Keep current photographs of residents at risk in a central location.
  • Any alarms designed to alert staff of possible elopement must be operational. A routine schedule for testing and maintenance is necessary.
  • Evaluate staff response to alarms and the actions staff take or fail to take when an alarm sounds.
  • Ensure that all staff act quickly when an elopement occurs and know how to proceed. This would include such actions as determining the whereabouts of all residents, an internal and external search of the premises, and the notification of police, family, and others according to a specific timetable.

Other resources are available at:

Alzheimer's Association - Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes:

If you have questions regarding this information, please contact the Assisted Living Regional Director for the appropriate Bureau of Assisted Living region. Contact information can be found at:


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Last Updated: September 30, 2011