Elopement (a personal story and a plea)

Nurses Safety

Published

Hello everyone! I joined AN a few months ago and love it! This is my first OP, and it is a long one, but please bear with me.

I wish I could type all about my grandma M, but where would I start? She was a lovely woman. Even after dementia ravaged her brain and took nearly all of her speech, she was always full of hugs and light-up-the-room smiles for her great-grandbabies. Every member of her family and many of the needy in her community had very warm and cozy feet because of her handmade slippers. :) She was mostly non-verbal, but if someone wrote the words "Mom" or "I love you" and asked her what they said, she could answer.

She also began wandering--almost non-stop. Her husband of over 30 years was very devoted to her and took care of her at home as long as he could. He had prosthetic hips and knees and was 90 yrs old, but when they were alone together he followed her at all times to make sure she was safe. He installed bells in their doorway so he would hear if she tried to leave the apartment. Two years ago however, the family together decided that for her safety and her husband's health, she should move into a memory care facility. Here she could walk to her heart's content and be safe.

One year ago this week, she eloped from her facility. She had a Wander Guard (or similar) device in place, but the door alarm never sounded. Once staff realized she was gone, the police were called immediately. Police, volunteers, and even the neighboring county's bloodhound went looking for her... but it was night in the upper Midwest, under 20⁰ F, and she was not dressed for the weather. She was gone by the time she was found.

I was sad that we lost her...I was devastated by how we lost her. I could barely get out of bed for two days when this happened, wondering if she was afraid or suffered or wondered why no one was coming to help her.

I will add too, that since her admission there had been no issues with her care. These were not bad nurses or CNAs. That time of night in LTC, there was probably one nurse and a couple CNAs on the floor. She was quick, and could have easily been gone in the time the two CNAs were stuck in a room doing incontinence care and the nurse was in another room giving a pain med. This was mainly the result of equipment failure.

Which brings me to my purpose in writing this. Does your facility have policies to address elopement risk? Quality control checks for the technology? If not, please consider approaching your nursing admin. You could help spare another elder the same death that my grandma died, and another family the pain of such a loss.

Wander guard products are run off batteries and should be checked frequently to ensure the battery isn't dead. Our policy is to check each residents wrist guard and chart daily with nightly checks on all doors to make certain they all lock when you walk up to it with a wander guard.

Equipment failure is not always preventable but they should have a system in place to check with logs to review.

Your grandma sounds like a wonderful lady. I am very sorry for your loss.

Specializes in SICU, trauma, neuro.

GrnTea, thank you for that.

Specializes in LTC.

Sorry about your grandma.

At my facility, we check the wanderguards every shift to make sure they're working, but we've still had a few issues. A couple weeks ago someone eloped and even though her wanderguard was working the alarm never went off when she left (fortunately, she had walked over to the assisted living facility next door). Day shift actually had someone elope once despite the locked door, working wanderguard, and alarm going off. Afterwards, we were told that due to fire regulations, if a resident pushes on the door for 10-15 seconds the door will open. So when I work nights and the door alarm goes off, we always make sure we find out why.

Specializes in NICU, PICU, Transport, L&D, Hospice.

I am sorry for your loss.

Some facilities use visual deterrents to help prevent elopement. Often advanced dementia patients misinterpret what they see, this can be used to provide illusions which might prevent some tragedies. For instance, a black area in front of external doorways will be interpreted by some as a deep hole which they will not cross. Sometimes using a familiar sign or symbol to deter them will work. For example, marking exits with DANGER or DO NOT ENTER may deter some wanderers. The down side is that others who are experiencing paranoia may have exacerbation of symptoms with the presence of those type of warnings.

I like the idea of service dogs who 'guard' external exits. They are trained to lead wanderers away from harm and to alert staff should the wanderer gain access to the door and put themselves in danger.

So sorry for your loss. Stand strong. We're all here for you.

Specializes in critical care, ER,ICU, CVSURG, CCU.

i am so very sorry for your loss......

the last ltc i was DON chg. nurses checked alarms beginning and end of shifts......there was this one lovely and so crafty little lady who could learn the exit code key pattern by watching staff and other family members key punch out......... we did not know she knew the code, until one evening my husband was trying to punch in to pick me up for dinner.....he messed up on trying to key punch in, she got up from a lobby chair entered the code and let him in....

Specializes in Gerontology RN-BC and FNP MSN student.
i am so very sorry for your loss......

the last ltc i was DON chg. nurses checked alarms beginning and end of shifts......there was this one lovely and so crafty little lady who could learn the exit code key pattern by watching staff and other family members key punch out......... we did not know she knew the code, until one evening my husband was trying to punch in to pick me up for dinner.....he messed up on trying to key punch in, she got up from a lobby chair entered the code and let him in....

We had this problem....and we mounted a hinged painting over the number pad....it solved it for us.

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