Care – Elopement / Unauthorized Absence

Elopement may occur when a Patient / Client / Resident leaves a healthcare organization without the healthcare provider’s knowledge of the departure or fails to return from a granted pass or leave. Those who elope may be at risk of self-harm and / or harm to a third party. This document contains information entered by HIROC Subscriber healthcare organizations (acute and non-acute) in the Risk Register application to help you in your assessment of this risk.

Key Controls / Mitigation Strategies

• Policies, Procedures and Elopement-Prevention Practices:
  • Adopt a validated, objective assessment tool / practice to detect and assess Patients/Clients/Residents at risk for elopement upon referral/initial assessment and ongoing
  • Assessment of mental status on admission and through hospital stay, as required
  • Elopement Risk Assessment policy
  • Application of highest observation level relative to the Patient / Client / Resident’s physical and emotional condition (close observation, constant observation, Psychiatric Intensive Care Area (PICA), sitter, security)
  • Hourly rounding on Patients
  • Appropriate levels of supervision planned for and provided – this includes increased staffing ratios where indicated
  • Committees for preparedness (i.e. Emergency Response, Code Yellow)
  • Develop and implement a decision tree/algorithm/guideline/policy for elopement / Code Yellow of both voluntary and involuntary Patients / Clients / Residents that includes:
    • Search procedures defining staff roles and responsibilities including conducting timely searches, regardless of the Patient / Client / Resident’s voluntary or involuntary status
    • The need to immediately notify the Most Responsible Practitioner (versus notification after the search)
    • Timely notification of the family/Substitute Decision Maker and police, if warranted
  • Completion of an incident report
  • Outings policy and algorithm to guide decision-making for the assignment of Patient/Client/Resident passes and privileges 
  • Expectations clearly articulated to Patients / Clients / Residents prior to leaving on approved pass
  • Patient / Client / Resident sign-out book with contact number
  • Staff to contact the Most Responsible Practitioner whenever a Patient / Client / Resident requests a taxi to ensure they can safely leave the premise alone
  • Policy for video, surveillance, retention and responding to requests from law enforcement
• Documentation:
  • Ensure complete, consistent, and timely documentation of:
    • The elopement risk assessment at the time of admission and at predetermined intervals, as applicable
    • Individual’s activities are monitored and documented in daily logs
    • Interventions to address the Patient/Client/Resident’s risk of elopement, goals to prevent harm to the Patient / Client / Resident and/or third parties (i.e. within Patient / Client / Resident’s care plan)
    • The steps undertaken in response to suspected elopements by voluntary or involuntary Patients / Clients / Residents including:
      • Who was contacted (security staff, Most Responsible Practitioner, family, police, etc.)
      • When Code Yellow / missing person policy was initiated
  • Photos of Patients / Clients / Residents for identifying individuals available for the purpose of searches by staff and police
• Post-Elopement Management:
  • Review and debrief of any Code Yellow incident
  • Debriefing and support processes for staff when elopement outcome results in unanticipated death or harm of the Patient / Client / Resident and / or third party
  • Assessment by Leadership / Quality / Clinical team regarding reason for elopement and follow-up investigations conducted, as appropriate
• Space Design and Environmental Safety:
  • Doors to departments are locked and secured
  • Controlled entrances to the facility
  • Swipe card access for all staff, volunteers, Patients / Clients / Residents and family
  • Limitations on how windows and doors are opened
  • Painted murals (exit diversion) on doors
  • Audible notification alarms on doors to alert staff that door has been opened
  • Emergency button at Reception/lobby area to be used when a Patient / Client / Resident is attempting to elope
  • Notice posted at main entrance reminding everyone to be aware of the Patients / Clients / Residents exiting the organization and to report suspected activity to Reception
  • Photos and names of people most likely to seek exit are posted at Reception where only staff can access
  • Signage asking staff and visitors to ensure the door is closed completely
  • Alarm on stairwell doors between specified hours
  • Room alerts in place
  • Fences on outdoor property that indicate safe spaces and reduce wandering
  • Furniture is kept away from fences 
  • Lattice installed on top of wood fence to increase height
  • Regular environmental assessments to evaluate units/buildings for risk of elopement
• Equipment / Potential Personal Safeguards:
  • Use of monitoring equipment and technology 
  • Identification (I.D.) bracelet and clothing labelled with Patient / Client / Resident’s name to aid in recovery if they elope
  • Patients/Clients/Residents wear colour-coded name badges with site address/phone number
  • Patients wear hospital clothing
  • Cell phones provided to individuals with higher independence levels
• Education (staff, Patients / Clients / Residents and family):
  • Staff education and compliance with applicable policies (i.e. Code Yellow policy, Elopement Risk Assessment policy, Managing Exploratory Behaviour policy, Gentle Persuasive Approaches (GPA) policy, and Outings policy)
  • Code Yellow training/drills with appropriate documentation (i.e. date, time and attendance)
  • Education upon Patient / Client / Resident admission
  • Involve family in care and communicate any risk of Patient / Client / Resident going absent without leave (AwoL)

Monitoring / Indicators

• Regular review of:
  • Number of people who elope per year
  • Number of Patient/  Client / Resident safety incidents involving elopement
  • Resident photos at Reception for relevance and level of risk and update, as needed
  • Number of staff trained on applicable policies
  • Percent unauthorized leave of absence (ULOAs) (ULOA days/Patient days in period x 100)
  • Number of hourly rounds on patients 
• Tracking and verification of Patient / Client / Resident attendance
• Elopement incidents reported to Board of Directors quarterly