Pathways to the Past
by Sandra Stimson ADC, CALA, CDP
Executive Director,
Alternative Solutions in Long Term Care
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SANDRA STIMSON
Executive Director
Alternative Solutions in LTC
and
National Council of Certified
Dementia Practitioners
http://www.nccdp.org  
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ABOUT SANDRA

Sandra Stimson has
experience as a corporate
consultant, Corporate Trainer
and National Speaker. Her
experience is in long term
care, as Activity Director,
Director of Alzheimer's Units
and Assistant Administrator of a
550 bed long term care county
Pet Express Pet Therapy Club,
is a Life Replay Specialist.  
Sandra implements dementia
units nationwide.  Sandra has
written several books,
Volunteer Management
Essentials for Long Term Care
and Pet Express Pet Therapy
Program. Sandra has been a
facilitator for Alzheimer's
support groups and is the
Awards Chair for the NJ
Association of Activity
Professionals.  Sandra is the
Executive Director of
National
Council of Certified Dementia
Practitioners
http://www.nccdp.org  

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Take Precautions for Facility Outing?
By: Sandra Stimson CALA, ADC, CDP, CDCM

Imagine these scenarios:

Scenario #1:
Activity Assistant takes 10 dementia residents to a large race track and loses one of the
residents. The facility staff are never notified. The Activity Assistant locates the resident
after a frantic search of over an hour. Fortunately, no one was injured.

Scenario #2:
A facility recently took their residents who lived on their dementia unit to New York City.
The City is very crowded and the staff lost a resident when the resident wandered off.”
Luckily, 24 hours later the resident was found by law enforcement who was wandering
the streets and was unharmed but exhausted and dehydrated.

Scenario # 3:
An assisted living facility took 8 dementia residents who were ambulatory, one activity
assistant and one bus driver to a crowded mall. They lost the resident for over an hour.
The resident was found unharmed. The elopement was never reported to facility staff or
local authorities.

Scenario # 4:
An activity assistant took 7 residents by herself to a large apple orchard. She had not
taken a cell phone and had no form of outside communication. All residents were
ambulatory and diagnosed with dementia and Alzheimer’s. She drove to an isolated
remote section of the huge apple orchard. She opened the van door and began letting
the residents out of the van. They immediately scattered. She was unable to call for
help. Luckily after an hour, she found all the residents. One resident had fallen in a
small hole but was unharmed

These scenarios are familiar all over the country. For the most part, the residents are
found and unharmed. But there are many more stories that result in injury and death.
Often times the elopement are not reported to law enforcement or state agencies.

In reading these scenarios what protocols were broken and how would you have
handled this situation. What action should administration take?

Residents diagnosed with dementia and or who live on a dementia unit may go on
supervised outings.  But the team needs to put thought and planning for facility trips.  As
a general rule, anyone that the team feels is not a flight risk should attend outings. As
long as there is appropriate staffing to provide supervision, observation and monitoring
at all times. Only take the number of residents that can be safely monitored.

On all trips there should be an activity assistant, nursing assistant and a bus driver. Or
two activity assistants and a nursing assistant.  A nursing assistant should accompany
all residents as they are trained in areas of ADL’s. Additionally, if you have only one
activity assistant and a resident has to go to the rest room, who will be left to monitor
the residents? Administrators and Director’s of Nursing must make it a policy to have
appropriate supervision when resident’s have a diagnosis of dementia are on facility
outings.  The facility is leaving themselves open for possible accidents, elopements,
fines and law suits should anything happen

But what if the person is a flight risk?  Flight risk may be anyone who is ambulatory or in
wheel chair or motorized cart who has wandered away before. But be aware that a
dementia resident who wanders away may never have wandered away from a
controlled area before. Staff must be alert to this possibility at all times. Plan for it,
Expect it.

The team for the dementia unit must meet and decide as a team what the safety issues
are, how you will meet those safety issues and which staff will provide the monitoring
and observations.  The team should make the decision on which residents will attend
facility outings. This should not be a decision made by the activity staff. Obviously,
anyone who is a flight risk must have one on one staff supervision at all times.

At times you have families who insist that their loved one attend a resident outing.
However, safety must come first. If you are not prepared to take this resident on an
outing due to inadequate staffing, supervision and monitoring concerns than you must
explain to the family. You might ask the family member or responsible party if they
would like to attend the trip and assist with their loved one.  Many people have no
concept of how hard a trip is and what is involved in a trip. It may be one of the hardest
and most exhausting of activities.

Pick the location well, as if a life depends on it.  The Activity Director should visit the
location prior to the trip to access the environment, crowds, bathroom facilities, parking
lot and number of exits for the location. Smaller venues are recommended such as;

  • Small diners
  • Small pet shops
  • Small stores
  • Small stores such as five and dime vs. a large shopping mall.
  • Drive to a resident’s old neighborhood
  • Small zoo
  • Ice cream parlors
  • Garden center

Plan your time well. Probably the best time to go on an outing is 10:00 A.M. and return
by lunch time.  A long trip is probably not recommended as they tire easily.  There are
times through out the year that you may want to take residents on trips where they do
not leave the van such as viewing holiday lights or observing fall foliage. Keep in mind
the weather and dress the residents accordingly.

Always communicate for success. Let the residents know where you are going.  When
you get off the bus, let the residents know what they will be doing. When they return,
state to the residents, “that you are now returning and the name of your facility.”  Keep
your answers brief and to the point.  There is a great communication book called
Creating  Moments of Joy and is available at www.activitytherapy.com web site. This
could be used as part of your in-service and training. The book provides excellent
responses for repeated questions, such as “I want to go home or where is my
daughter, etc.”

Dementia residents may leave the facility willingly but once on the bus may become
agitated. Staff must be seated in the center, back and front of the bus to monitor your
residents. If a dementia resident becomes so agitated that you can not calm them
down, than return to the facility. Often times, by calmly stating where you are going may
be enough to diffuse the situation. Use good communication skills, speak at eye level,
be sure they focus on your eyes, state one sentence at a time and allow them time to
digest what you have just said.

Clearly document any significant event while on the trip such as outbursts, elopement,
agitation, etc. The staff should note the behavior and interventions used to calm the
resident down.

Upon returning, it may be difficult to bring residents back to the unit. Try sitting down for
a few minutes and offering a snack and than try again. If that does not work, try showing
them a picture and asking their opinion of the picture. Than try again to slowly guide the
resident to the unit. If that does not work, try the Nursing Assistant they have the best
rapport with, often times that will work.  If this is a consistent problem, consider not
taking the residents. They may be upset for days and not even remember why.     

Here are some tips for planning for the trip:
  • Involve the team and discuss who is attending the outing. Obtain approval from
    the team for the individuals to attend.
  • Follow all policy and procedures and guidelines for elopement risks.
  • Obtain responsible party permission for each outing.
  • Make sure you have doctor’s orders for the resident to leave the facility and
    attend outings.
  • Bring a charged cell phone.
  • Provide a completed Trip Form to all department heads, Supervisors and
    Administrators that clearly shows the name of the event, of the date of trip, venue
    name, address, phone number and resident’s names who are attending the
    trip. Departure time and return times are also important. List your cell phone
    number on the form. List the staff names who will be attending the outing.
  • On all trips, bring along snacks, crackers, orange juice and apple juice. There
    are times when the bus may be delayed due to accidents and traffic.  You may
    also have a resident who is diabetic.  Also bring along extra diapers, wipes,
    trash bags and paper towels in the event of accidents or spills.
  • Staff should be seated through out the van.  As a resident may attempt to get out
    of their seat. It is important that one staff member is seated in the back of the
    bus to observe for safety concerns or illness issues
  • Plan trips to small venues such as small diners, small pet shops, tiny stores,
    drive bys such as Christmas lights and parks featuring gardens. It is strongly
    advised that you do not take outings to large crowded venues such as State
    Fairs, Big Cities, Malls, etc.
  • Find venues where you can park right next to the door. Avoid huge parking lots.
  • Find venues that are soothing and quiet vs. noisy and crowded. Call ahead and
    find out times they are not busy.
  • For restaurants, ask for tables closest to the rest rooms.
  • Be aware of all exits
  • Be aware of all bathrooms and never leave them unattended in the bathroom.
  • Keep trip outings short. A few minutes drive to and from location. No more than
    an hour at location as dementia residents tend to tire easily.
  • Alert Director of Nursing and all nursing supervisors that you have returned.
  • Document any issues or concerns you had regarding specific residents who
    attended the trip.
  • All residents should have proper identification.  One creative way is to have the
    residents and staff wears T shirts that have the name of the facility printed on the
    front and back. This should be a bright color such as yellow because it is easy
    to spot. This is really important in the case of elopement and First Responders
    need to know exactly what the resident was wearing. It is a quick visual way to
    monitor and supervise the residents
  • Ensure they are wearing their facility ID bracelets.
  • Count residents every 5 minutes to insure you are aware of their location.  If you
    do this and you have an elopement, the resident has only a few minutes head
    start.
  • Staff should know the facility Trip protocol in case of an injury, fall or illness.  
  • Ensure sure staff are trained to react when there is elopement and to follow your
    protocol.

If there is an elopement or walk away, call the facility immediately and report to the
Director of Nursing and or Administrator.  Ask if you should now call 911. Keep reporting
in or even better, do not hang up your phone, to keep an open line of communication as
this is a critical situation.  Time is not on your side.  Residents can wander into traffic,
fall and any of a number of serious injuries and accidents can occur. Remember there
are only two kinds of people who may find your resident, a Good Samaritan and law
enforcement.  Let’s be honest.  Yes, you may stop to help an elderly man wandering the
streets in a small town, but would you stop the same elderly man in a large city? We
hope the answer is yes but most often it is Law Enforcement who locates a dementia
resident

The facility should immediately send a supervisor to the location.
At some point if staff can not find the resident, since time is critical and not on your side
in the event of an elopement, the staff should call 911. 5 Minutes is more than enough
time to do a search of a small venue.  Every minute counts because statistically if you
do not find them in 24 hours depending on weather may result in a fatality. But to be
safe, we recommend contacting 911 immediately and not waiting.
Depending on the amount of time the resident was not located(in some cases you find
them in a minute), families or responsible party must be notified, state surveyors need
to be notified and in some states other authorities need to be notified. An incident report
will need to be completed immediately.

The Wandering Committee should meet immediately to discuss how this happened,
why this happened and discuss protocols to prevent this from happening again.
Wandering Committee Guidelines are available at www.activitytherapy.com
Keep resident pictures up to date and place on the chart and update every year or if
there is a significant change such as weight loss.

Keep the scent on the chart. Two ways suggested such as placing a pair of socks on
resident from a sealed bag. The resident would wear the socks for several hours than
staff wearing gloves would remove and place in plastic sealed bag. Another way is to
take a sterile wash cloth from a sealed unopened bag and wipe under residents arms,
back of neck etc and place in a sealed bag. You may need scent for dog tracking.
The Activity Director should in-service all the activity assistants and document that an in-
service was conducted that deals specifically with Trips, elopements and emergencies.
Provide a copy of the Trip policy.  The in-service should specifically state what to do in
situations of elopement, illness, falls and accidents and the reporting procedures. For
example, is the Executive Director to be notified first? When do they call 911? Safety on
the Bus is another area to in-service staff. They can never let their guard down.  Any
elopement or missing resident is to be reported immediately before the search begins.
Take pictures of the bottom of resident shoes. The police may need this when tracking
the resident.

Know your resident. Complete thorough initial assessments. Ask family if they have
eloped before, what the triggers were, what they did, how they handled the situation,
where might they go and what name they might answer to. Complete Wandering
Information Sheets and keep them up to date.  See resources.
There should be a strong policy and procedure that deals with facility trips, elopements
on trips as wells as falls, illness and injury on trips. Many facilities have elopement
policies but unfortunately and legally that does not pertain to facility trips. Administration
should carefully review the activity department policy and protocol for trips and
incorporate procedures to follow for elopement, injury, falls and illness when on trips. At
minimum the policy should address:

Van Safety
  • Seat Belts
  • Loading and unloading
  • Emergencies
  • Falls
  • Elopement
  • Illness
  • Food required to be on van for trips
  • Gas & Inspection of Van
  • Cell Phones
  • Staffing for the Trips
  • Proper reporting procedures
  • When to call 911
  • Trip request form
  • Training staff on use of Van
  • Bus Driver
  • Required CNA per trip
  • Documentation required for elopements, illness, injury or falls.  
  • Who to notify
  • Who will search
  • Which areas will be searched and their priority
  • Who will notify authorities, if necessary
  • Who will notify family members
  • Who will coordinate the search efforts

The Activity Director should have a Trip book that includes:
  • The name of each location
  • Address
  • Phone number
  • Rest room information
  • Ramp information
  • Directions
  • Cost

Facility Trips and outings are very beneficial to the dementia resident. Some of the
benefits are:
  1. Relaxation
  2. Reminiscing about the location
  3. Fun
  4. Self Esteem Building
  5. Diversion
  6. Pleasurable
  7. Calming
  8. An opportunity for reminiscing
  9. Community Interaction
  10. Decrease restlessness
  11. Sensory stimulation

Once you find a resident who has wandered away from the venue remember to:
  • Remain calm and smile.
  • Introduce yourself and your position.
  • Not scold them or reprimand them.
  • They may need a hug.
  • Offer fluids and a snack.
  • Provide a blanket if cold.
  • Talk slowly and soothingly as you make your way back to the facility van.
  • Ask them if you can give them a ride back to the facility.   
  • Alert all parties including First Responders that you have located the resident.
  • Remember, they can not navigate back home.

There are also many products on the market for tracking elopements such as GPS
systems. If you feel you may need additional support in the event of a possible
elopement, you might investigate Project Lifesaver. Project Lifesaver has great success
in locating missing residents in a matter of minutes.

You can avoid catastrophic reactions and situations if the Activity Director, Director of
Nursing and Executive Director conduct thorough assessments for wandering
potential,  train the staff, plans the venues, provides enough staff on outings,
communicate with the other staff in the facility, use technology, have reporting
procedures and have strong policies and procedures.

RESOURCES

Fantastic Resource on our web site is the Elopement Manual and is a free download:


Wandering Information Sheet-Free Download should be completed and placed in every
residents chart who you feel may be a risk for elopement.

Read this article on Nursing Home Lawsuit Due to Injuries Sustained During a Facility
Trip and Elopement:

Assisted Living Resident Wandered Away and Activity Director Named in The Law Suit.


WanderCare- GPS System

Eight Steps To Protect Dementia Residents

Locating Devices Fact Sheet


Missing Persons / Wander Information Sheet

See Complaint Case VIII A page 3 where no enforcement action taken because the
facility did everything they could to prevent elopement.

Wandering Tips from New Zealand


Care Givers Fact Sheet: Wandering

Wandering Committee Guidelines

Dementia Care Plans

Project Lifesaver

LoJack SafetyNet

Silver Alert