Elopement in Assisted Living: Lessons from Real Incidents and How to Prevent Them

Elopement in assisted living isn’t just a policy failure; it’s a critical safety issue that can result in tragic outcomes. As healthcare professionals, we know that residents with cognitive impairments or mental health conditions are especially vulnerable. But recent investigations in Ohio have revealed just how devastating the consequences can be when systems fail.

Why Elopement in Assisted Living Remains a Critical Safety Concern

One case involved a resident with Alzheimer’s who exited the facility unnoticed through an unalarmed egress door. He was found deceased hours later in the snow, having succumbed to hypothermia. Another resident, cognitively impaired but physically

independent, signed out to go to the store and was missing for over 18 hours. He spent the night in his car, missed medications, and was hospitalized.

These incidents weren’t isolated – they were systemic. Staff failed to notice absences, documentation was inaccurate, and communication breakdowns delayed response. In both cases, the facilities were cited for failing to provide adequate supervision and protect residents from harm.

So, what can we learn?

Assisted living communities must implement:

• Comprehensive risk assessments on admission and with any change in condition.

• Updated sign-out protocols that include expected return times and emergency contact info.

• Routine audits and missing resident drills to reinforce staff readiness.

• Door security upgrades, including alarms, signage, and staff alert systems.

• Staff education on elopement risks, prevention strategies, and emergency response.

Elopement prevention is not just about locking doors, it’s about creating a culture of vigilance, accountability, and individualized care. Residents at risk must have tailored service plans, and staff must be empowered to act quickly and decisively. Explore Ohio’s regulatory framework for Residential Care Facilities here.

If your community is unsure whether its elopement protocols are sufficient, or if you’ve experienced a close call, the Engage Consulting team is here to help. We offer regulatory guidance, operational support, and training programs to strengthen your safety systems and protect your residents.