Wandering patients need response plan

Resident elopement and wandering can be extremely dangerous for patients and costly to the facility if the patient is injured or dies, but many health care providers do not have a formal plan in place to prevent the problem or respond effectively once staff realize a patient is missing.

Patients who wander and elope should be a top priority for risk managers, says Carolyn Caccese, JD, attorney, Salenger, Sack, Schwartz & Kimmel, New York City. These incidents frequently lead to lawsuits, and the payouts can be significant if the patient is injured or even dies during the absence, she says.

Caccese notes that wandering and elopement go hand in hand with another major worry for risk managers — falls. Many of the same patients who go missing are the same ones at risk for falls, so the liability risk can be heightened.

"Patients who usually wander often have compromised mental states, so falls are very, very common," she says. "The injuries can range from bumps and bruises to a fractured hip that requires surgery. A lot of these patients who are compromised just can't recover well from the surgery, so a lot of the patients end up passing away within two years of the fall. That makes wandering a very concerning event."

Caccese notes that the danger exists even if the patient is unable to leave the premises. Elopement from the facility certainly increases the risk in several ways, but a patient who wanders around the hospital or long-term care facility still can be endangered by falls and other hazards, she says.

Nursing staff responsible

Patients wander for various reasons, says Maria Rosario Gonzales, RN, a nurse educator in the Veterans Administration Healthcare System in Los Angeles.

"They may seek escape from a psychiatric unit or hospitalization, want to go home, be confused, and just go for a walk," Gonzales says. "Whatever the reason, the nursing staffs are accountable for the patient's well-being and safety. In the worst-case scenario, a confused patient may wander off and suffer hypothermia or increased medical complications due to hypothermia and may miss necessary cardiac, anticoagulant, or seizure medications."

In psychiatric settings, the patient may want to escape to attempt suicide, notes Sharon Valente, RN, PhD, an adjunct assistant professor at the University of Southern California, Los Angeles.

"Whatever the reasons for the wandering, the nursing staffs are accountable for the patients, and they grieve when patients leave and worry about the serious life-threatening consequences of failing to prevent the wandering," she says. "In addition, the . . . economic, legal, and professional consequences of wandering are serious."

Liability dependent on precautions

A health care provider's liability for injuries or death following wandering or elopement will depend on what precautions were taken to prevent the incident and how the facility responded, Caccese says. The safety measures will be evaluated to determine if they were adequate for that location and what was known about the patient's propensity to wander or elope, she says.

"Unfortunately, there are some patients who, even with all the safety measures, can still wander and something bad happens to them. If you can show that you took all the correct, reasonable steps to prevent this tragedy, and nonetheless it still happened, you may be able to successfully defend yourself," she says. "But if those safety measures were not documented in the file, these cases often settle. These cases can be indefensible if you have a patient with altered mental status and a history of wandering and the record doesn't show any effort to prevent this person from getting out of bed or their room."

Most facilities have a policy on preventing wandering and elopement, but Caccese stresses that the patient's record must show the staff complied with that policy.

"Having the policy is necessary, but if you don't document compliance, it can do more harm than good," she says. "It is a big gift to the plaintiff if the policy exists, but there is no evidence that you complied with your own policy."

Caccese has worked on cases that deal with patients injuring themselves in both hospitals and long-term care facilities due to improper supervision, and most involved confused patients who leave their bed or room and sustain a fall. Often, the patients have been elderly and on medications that contribute to their confusion, she says. In New York, as in some other states, causes of action alleging in negligence and malpractice can be brought, in addition to a statutory cause of action created by the Public Health Law.

"If the facility deprives a patient of a right or benefit, or violates a federal or state statute, the patient may utilize this theory of liability beyond just a malpractice case," she explains. "The Public Health Law sets out a minimum amount of damages recoverable, at least 25% of the daily nursing home rate, and even subjects the facilities to punitive damages. Given the wide range of circumstances where this cause of action can be asserted, it is useful for patients and a serious potential liability concern for providers."

Caccese recounts one recent case in which she represented a woman who fell while trying to exit her bed and, though she was not injured in that incident, the facility did not take any additional precautions to prevent her from wandering. Two days later the woman left her bed, exited her room, and traveled down the hall unnoticed by staff. When the staff realized she had left her room, they searched and found her on the floor where she had fallen after tripping over some wires hanging off of a gurney. She broke her hip and subsequently sued the hospital.

"We ended up settling the case after depositions, because the hospital could not prove it had taken adequate measures, especially after the first fall," she says. "Their documentation did not show that they placed the patient at risk for falls or elopement. We were able to prove that they violated their own policy."

Search grid improves response

Gonzales and Valente studied wandering and elopement in the Los Angeles Veterans Administration facility and found that in a six-month period, 16 patients walked off wards without notification to staff, 13 were missing after privileges were granted, 11 failed to return after being given a pass, nine failed to return after fresh air or smoke breaks, and eight inpatients failed to return after they went for a clinic appointment.1

Most of the patients were reported missing during the day shift, Valente says. After studying the root-cause analyses for the incidents, Gonzalez and Valente made these two key conclusions:

• The lack of unit- or ward-specific search grids slowed the response and caused the preliminary search to be inefficient and ineffective. Staff should be familiar with a response plan that calls for searching the area in a deliberate, coordinated effort.

• Communication during the searches was repetitive and chaotic. Staff did not reference the physical layout of the unit when giving directions regarding where to search, which prolonged the preliminary search.

After educating the staff about the missing and wandering patient policy, Gonzalez and Valente designed a mock drill to evaluate the effectiveness of the facility's policy on missing patients. They announced a facilitywide wandering and missing patient mock drill, which required each unit to use a specific grid to search for the missing patient. The first drill used a generic sample grid to show staff how the tool could be of use, and they found that using the unit-specific search grid helped the staff communicate effectively with each other and organize the search to find the patient and reduce the risk that the patient was harmed. The hospital then directed each unit to develop its own specific grid for use in conducting a preliminary search.

Caccese says such an organized program for finding missing programs could significantly reduce the potential liability for patient injury and liability.

"Preventing the wandering or elopement is the best thing, but it is still going to happen sometimes. Having a response plan that is effective, something that is more coordinated and organized than just telling people to look around, will always be good," she says. "Beyond that, educating your staff about the proper documentation of your compliance with these policies is the best thing you can do."

Reference

1. Gonzales MRD, Valente S. The wandering & missing patient: reducing the risk for harm & injury, an evidence-based performance improvement project. 2004: Veterans Administration Healthcare System, Los Angeles.

Sources

For more information on wandering and elopement, contact:

• Carolyn Caccese, JD, Attorney, Salenger, Sack, Schwartz & Kimmel, New York City. Telephone: (212) 267-1950.

• Maria Rosario Gonzales, RN, Nurse Educator, Veterans Administration Healthcare System, Los Angeles. Telephone: (310) 478-3711. E-mail: maria.gonzales@med.va.gov.

• Sharon Valente, RN, PhD, Adjunct Assistant Professor, University of Southern California, Los Angeles. Telephone: (310) 478-3711. E-mail: sharon.valente@med.va.gov.