Elopement Risk Assessment - LTC Forum
Elopement Risk Assessment
Instructions: Upon admission and quarterly (at a minimum) thereafter, assess the resident status in seven clinical areas listed below (1-7) by assigning the corresponding score which best describes the resident in the appropriate assessment column. Add the column of numbers to obtain the total score. If the total score is 10 or greater, the resident should be considered to be at risk for elopement. Prevention protocols should be followed and documented on the care plan.
|Item |Score |Resident Status/Condition |Date |Date |Date |Date | | | | | | | | | | |1 |Mobility |0 |Needs total assistance | | | | | | | |2 |Propels self/some assist | | | | | | | |4 |Fully ambulatory | | | | | |2 |Mental stability |0 |Alert oriented x3 | | | | | | | |2 |Disoriented/no wandering | | | | | | | |4 |Wanders aimlessly | | | | | |3 |Emotional status |0 |Happy with placement | | | | | | | |2 |Content with placement | | | | | | | |4 |Voices desire to leave | | | | | |4 |History elopement
Attempts |0 |No attempt | | | | | | | |4 |Voices, but no action | | | | | | | |10 |Has made 1 or > attempts in last year | | | | | |5 |Behavior Modifications |0 |No behaviors noted | | | | | | | |2 |Behaviors redirected | | | | | | | |4 |Difficult to redirect | | | | | |6 |Medications (antipsychotic, mood altering) |0 |None of these | | | | | | | |2 |1 of these meds | | | | | | | |4 |2 or more of these meds | | | | | |7 |Disease’s (dementia any type mental illness) |0 |None present | | | | | | | |2 |1 present | | | | | | | |4 |2 or more present | | | | | | |Total Score | |10 or more >risk | | | | | |
If elopement assessment score is 10 or greater resident is considered an elopement risk.
If at risk for elopement, what safety measures are being implemented?
□ Wander bracelet / roam alert
□ Safety checks – Indicate 1 hour; 30 minutes; 15 minutes
□ Encourage diversional recreational activities
□ Other __________________________________________
Name/Title of Person Completing Form:____________________________ Date:___________
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