Run Memory Care Elopement Risk Assessment — Free

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 critical (required)

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 critical (required)

Enter the name and role/title of the staff member completing the assessment.

Cognitive and Orientation Factors

Disoriented to place or unit critical (required)

Resident is unable to reliably identify their location or memory care unit.

Yes No N/A

Disoriented to time or date

Resident demonstrates inability to orient to current time, date, or day of week.

Yes No N/A

Unable to recall safety instructions after brief delay critical (required)

Resident cannot retain simple safety direction such as staying with staff or asking for assistance.

Yes No N/A

Impulsive decision-making observed

Resident acts without regard for safety, supervision, or redirection.

Yes No N/A

History of confusion increases during evening or overnight hours

Resident shows sundowning or time-of-day-related confusion that may increase exit-seeking risk.

Yes No N/A

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 critical (required)

Resident has been observed wandering aimlessly or repeatedly moving through the unit without purpose.

Yes No N/A

History of exit-seeking behavior critical (required)

Resident attempts to leave the unit, asks to go home repeatedly, or targets exits/doors.

Yes No N/A

Prior elopement incident documented critical (required)

Resident has a documented past elopement or unauthorized exit event.

Yes No N/A

Agitation or restlessness observed

Resident shows pacing, repeated standing, or inability to remain settled despite redirection.

Yes No N/A

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 critical (required)

Resident can walk independently and may be able to reach exits without assistance.

Yes No N/A

Transfers independently

Resident can rise from bed, chair, or wheelchair without staff assistance.

Yes No N/A

Can open doors, gates, or latches critical (required)

Resident has the physical ability and dexterity to operate common exit hardware or bypass barriers.

Yes No N/A

Requires continuous or frequent supervision critical (required)

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.

Yes No N/A

Environmental and Security Controls

Exit alarms or door alerts functioning critical (required)

Door alarms, delayed egress alerts, or equivalent notification systems are active and operational where used.

Yes No N/A

Secure perimeter or controlled access in place critical (required)

Memory care area has controlled access appropriate to the resident's elopement risk and care plan.

Yes No N/A

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.

Yes No N/A

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 critical (required)

Resident care plan includes current risk level, supervision needs, and prevention interventions.

Yes No N/A

Staff and family notified of risk status

Appropriate staff and responsible party/family have been informed of the current elopement risk and precautions.

Yes No N/A

Follow-up actions documented

Record any required interventions, monitoring changes, referrals, or reassessment date.

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Run: Memory Care Elopement Risk Assessment

Assessment Details

Cognitive and Orientation Factors

Behavioral and Elopement History

Mobility, Independence, and Supervision Needs

Environmental and Security Controls

Prevention Plan and Follow-Up

Get your results