Memory Care Elopement Risk Assessment

Standardized inspection template for assessing elopement risk in memory care residents using observable cognitive, behavioral, mobility, and environmental factors to support prevention planning and safety controls.

Assessment Details

• Resident identifier recorded
  Enter the resident's chart identifier or internal resident ID. Do not enter full SSN or other sensitive identifiers.
• Assessment date and time recorded
  Record the date and time the elopement risk assessment was completed.
• Assessment trigger documented
  Select the reason the assessment is being completed.
• Assessor name and role documented
  Enter the name and role/title of the staff member completing the assessment.

Cognitive and Orientation Factors

• Disoriented to place or unit
  Resident is unable to reliably identify their location or memory care unit.
• Disoriented to time or date
  Resident demonstrates inability to orient to current time, date, or day of week.
• Unable to recall safety instructions after brief delay
  Resident cannot retain simple safety direction such as staying with staff or asking for assistance.
• Impulsive decision-making observed
  Resident acts without regard for safety, supervision, or redirection.
• History of confusion increases during evening or overnight hours
  Resident shows sundowning or time-of-day-related confusion that may increase exit-seeking risk.
• Cognitive risk level
  Overall cognitive contribution to elopement risk based on current observation and record review.

Behavioral and Elopement History

• History of wandering within the last 90 days
  Resident has been observed wandering aimlessly or repeatedly moving through the unit without purpose.
• History of exit-seeking behavior
  Resident attempts to leave the unit, asks to go home repeatedly, or targets exits/doors.
• Prior elopement incident documented
  Resident has a documented past elopement or unauthorized exit event.
• Agitation or restlessness observed
  Resident shows pacing, repeated standing, or inability to remain settled despite redirection.
• Triggers for exit-seeking identified
  Select known triggers that increase the resident's likelihood of leaving unsafely.
• Behavioral risk level
  Overall behavioral contribution to elopement risk based on observation and recent history.

Mobility, Independence, and Supervision Needs

• Ambulates independently without assistive device
  Resident can walk independently and may be able to reach exits without assistance.
• Transfers independently
  Resident can rise from bed, chair, or wheelchair without staff assistance.
• Can open doors, gates, or latches
  Resident has the physical ability and dexterity to operate common exit hardware or bypass barriers.
• Requires continuous or frequent supervision
  Select the current supervision level needed to reduce elopement risk.
• Gait or balance concerns increase fall risk during wandering
  Resident has gait instability, poor balance, or fall risk that may complicate safe redirection or wandering management.

Environmental and Security Controls

• Exit alarms or door alerts functioning
  Door alarms, delayed egress alerts, or equivalent notification systems are active and operational where used.
• Secure perimeter or controlled access in place
  Memory care area has controlled access appropriate to the resident's elopement risk and care plan.
• Exit routes are monitored and unobstructed for staff response
  Staff can visually monitor common exit routes and respond quickly to an alarm or attempted exit.
• Identification and tracking measures in use
  Select resident-specific measures used to support safe location and recovery if the resident leaves the unit.

Prevention Plan and Follow-Up

• Care plan updated to reflect elopement risk
  Resident care plan includes current risk level, supervision needs, and prevention interventions.
• Staff and family notified of risk status
  Appropriate staff and responsible party/family have been informed of the current elopement risk and precautions.
• Follow-up actions documented
  Record any required interventions, monitoring changes, referrals, or reassessment date.