HLTH 4303 Module 3 Risk Management Plan Example

Found at the Bus Stop: A Risk Management Plan for Elopement of Residents With Dementia at a Skilled Nursing Facility, From Assessment to Missing-Resident Drill

Student Name

American College of Education

HLTH4303: Legal and Ethical Issues in Healthcare Administration

Module 3 Assignment

Instructor Name

October 19, 2026

The Near Miss

Last month, a resident of our composite 120-bed skilled nursing facility, an 81-year-old man with moderate Alzheimer's disease, walked out of a side door behind a visitor at 4:40 in the afternoon. The door's alarm sounded, but staff on the unit assumed it had been set off by the visitor. He was found forty minutes later by a police officer at a bus stop half a mile away, in a light shirt on a cold evening, unhurt. His care plan noted that he had asked repeatedly to go home to his wife, who had died six years earlier. It was the facility's second elopement in a year.

In risk management, a near miss is an event that could have caused harm and did not. It is also the cheapest warning an organization receives. This paper sets out the facility's legal exposure, the causes of elopement identified in research and in our own review, and a plan to reduce the risk, with measures to show whether it works.

Legal Duties and Exposure

Under the federal rules for long-term care, a facility must see to it that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents (Requirements for Long Term Care Facilities, 2024). State surveyors cite elopements under this requirement, and a finding that a resident with a known risk left unsupervised can be cited at a level of actual harm or immediate jeopardy, with civil money penalties.

Civil liability is the second exposure. A resident who elopes and is injured, or dies from exposure or a traffic accident, gives the family a strong negligence claim when the facility knew of the risk and did not act on it. The elements of negligence, duty, breach, causation and damages, are easy to establish in such cases, because the facility's duty of supervision is clear and its records usually show whether the risk was known. Our resident's care plan documented his repeated wish to go home. A documented risk with no documented response is the pattern that turns an elopement into a lawsuit.

Why Residents Elope

Research on wandering and elopement explains both the behavior and the ways facilities fail to prevent it. Algase et al. (2007), reviewing 183 articles on dementia-related wandering, proposed a definition that treats wandering as a pattern of locomotion with its own features of frequency, timing and direction, and noted that the behavior has sometimes been treated as purely negative when parts of it may be purposeful or beneficial. That matters for planning: a resident who walks with purpose toward a door is often trying to get somewhere, such as home or work, and the response should address that purpose, not only block the exit.

Aud (2004) analyzed reports of 62 elopements of residents with dementia from long-term care facilities and found three recurring patterns: a lack of effective precautions when residents had expressed an intent to leave, had tried repeatedly or had eloped before; a lack of staff awareness of where residents were; and ineffective use of alarm devices intended to alert staff. All three patterns appear in our near miss. The resident had expressed intent, staff did not know he had reached the side door, and the alarm was dismissed.

The Plan: Identify, Prevent, Respond

The plan has three parts. Identification: every resident will be assessed for elopement risk on admission, quarterly, after any change in condition and after any attempt, using a short tool that records diagnosis, cognitive status, history of exit seeking and expressed intent to leave. Residents at high risk will have a current photograph and description in a binder at each nursing station and at the front desk, and their care plans will describe what they are looking for and what calms them.

Prevention: exit-seeking residents will have individualized plans that address the purpose behind the behavior, such as a scheduled walk outdoors with staff in the late afternoon, when exit seeking peaks, or a familiar task. Door alarms will be tested every day and the results logged, and staff will be trained that every alarm is answered by going to the door and accounting for residents, whoever seems to have set it off. Visitors will receive a card at entry asking them not to hold doors for residents.

Response: when a resident cannot be found, staff will follow a missing-resident procedure with timed steps: a search of the unit and building within ten minutes, notification of the administrator and director of nursing, a search of the grounds and, if the resident is not found within twenty minutes, a call to police with the resident's photograph and description. The facility will run a missing-resident drill on each shift every quarter. Drills will be unannounced, will use a staff member playing the missing resident in a different part of the building each time, and will be timed from the moment the resident is noticed missing to the moment the building search is complete. Results will be reviewed with the staff who took part, because a drill that is not debriefed teaches little. The first drills are likely to reveal gaps, such as staff who do not know where the photo binder is kept or which exits to check first, and finding those gaps in a drill is far better than finding them during a real search on a winter evening.

Balancing Safety and Freedom

Elopement prevention can easily become confinement. Locking every door or moving every resident who walks to a secured unit would reduce elopements but would also restrict residents' freedom, which federal rules protect, and could worsen distress in residents who walk to relieve anxiety. The plan therefore reserves the secured memory care unit for residents whose risk cannot be managed with individualized plans, requires an interdisciplinary review and family involvement before any transfer, and reviews each placement quarterly. Wearable alert devices will be used only when the resident or representative agrees. A plan that prevents harm by taking away a resident's ability to move freely has solved one problem by creating another.

Measures and Accountability

The plan will be judged by five measures reported monthly to the quality assurance committee: the number of elopements and attempted elopements; the percentage of residents assessed on schedule, with a target of 100%; the percentage of daily alarm tests completed; drill results, including the time to complete the building search; and the number of residents on the secured unit, to watch for over-restriction. The director of nursing owns the assessment and care planning measures, the maintenance director owns the alarm tests, and the administrator owns the drills and the monthly report. Every attempted elopement will be reviewed within 72 hours using a short root cause form, so that the facility learns from each event rather than waiting for the next one to cause harm.

References

Algase, D. L., Moore, D. H., Vandeweerd, C., & Gavin-Dreschnack, D. J. (2007). Mapping the maze of terms and definitions in dementia-related wandering. Aging & Mental Health, 11(6), 686-698. https://doi.org/10.1080/13607860701366434

Aud, M. A. (2004). Dangerous wandering: Elopements of older adults with dementia from long-term care facilities. American Journal of Alzheimer's Disease & Other Dementias, 19(6), 361-368. https://doi.org/10.1177/153331750401900602

Requirements for Long Term Care Facilities, 42 C.F.R. pt. 483, subpt. B (2024).