ELOPEMENT FROM FACILITIES
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Common Elopement Cases
What could have been done to avoid Elopement?
Legal expert, Michael Panish, explains and outlines anti elopement hardware
and egress requirements for life safety of long-term care facilities,
mental healthcare facilities, dementia wards, psychiatric facilities,
and residential care facilities. He describes common elopement cases.
By Michael Panish, Gate Expert Witness & Consultant
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WHAT IS THE DEFINITION OF ELOPEMENT?
An act or instance of leaving a safe area or safe premises, done by a person
with a mental disorder, cognitive impairment, or will to leave.
As an electrical building contractor and door, lock, and security contractor,
my company has been called upon to install, inspect, and maintain security
systems critical to protecting resident populations. These systems include
installation of door hardware such as magnetic locks, delayed egress panic
devices, and radio activated proximity systems specific to location needs.
These installations often require integration with central alarm monitoring,
life safety, and general compliance with ADA (American with Disabilities
Act) access points. Another layer of protection for residential care facilities
involves overall security cameras to assist the facility in observation
of the property. My company does not provide general alarm monitoring
services. As a licensed electrical building contractor, I have worked
closely with alarm companies that need professional installation of specified
products requiring a door hardware or electrical contractor trained to
install life safety access points and closed-circuit video monitoring devices.
WHAT LEVEL OF SECURITY IS EXPECTED?
Various types of occupancies include everything from assisted living programs
where the residents are provided food and board but are not required to
have ongoing immediate supervision to psych facilities, Alzheimer’s,
and memory care units where attending staff is required. Other secure
facilities have included lock down holding wards in hospitals and prisons
where a variety of electro-mechanical systems are employed to stop egress,
alert staff, and protect occupants that are often violent, confused, or demented.
In all cases, the security and safety of all patients and inmates is paramount.
It is necessary to recognize that there are egress requirements that need
to be in place according to fire prevention ordinances and other local
code enforcement authorities to make these types of buildings safe, habitable,
and occupied with a reasonable measure of protection for all. Different
types of facilities are regulated according to need and are not universal
in all egress requirements.
In this basic and general article, I am not providing any commentary regarding
the agency requirements, governmental oversight, or management obligations
relevant to the various types of care facilities. I am only providing
information regarding doors, egress systems pertaining to elopement prevention,
and hardware operations in these locations.
GENERAL RESIDENTIAL SECURITY
In most low risk elopement locations such as long-term elderly care facilities
or RCFE (Retirement Communities for the Elderly), the requirements for
exterior security are generally similar to a residential home which has
a perimeter alarm. In some of these facility locations where exit doors
remain largely unused, there are basic localized audio alarm units commonly
installed. Sometimes those local audio alarms are integrated into the
facility monitored alarm system, other times they are independent local
noise makers. With these types of residential care facilities, there is
not a general concern or need to continuously observe the residents since
they are free to come and go as they wish. The local alarm is just used
as an indicator that someone has attempted to exit through a specific
opening. Usually, there will be some posted signage near the alarmed door
to alert a user that an alarm will sound if the door is opened without
supervision by an authorized user. Signs such as “not an exit”
or “alarm will sound” are often placed next to these exit points.
WHY AN AUDIBLE ALARM?
In some installations, a low usage doorway will have a local audible alarm
siren sound and usage of that exit door may be connected to a general
building envelope alarm system that chirps if the door is opened. This
siren or chirping may be local to the door or happen remotely in a nursing
station or office administration area. Depending upon the desire of the
facility and the occupancy type, that level of alarm may be sufficient,
acceptable and meets the standard of care.
WHAT IS A PANIC DEVICE AND DELAYED EGRESS?
Horizontal crash bars positioned on exit doors are often referred to as
panic devices. No special knowledge is required to open a panic device
egress door other than the ability to bang on the horizontal metal strip
and push the door outward in the path of travel. Frequently, panic devices
placed on exit doors have delayed egress functions with audible alarms.
These are commonly associated with an alarmed exit point. Delayed egress
means that when a panic device is pushed the door will not unlock for
a predetermined set period of time. Once the delayed egress panic device
is pushed, an alarm will continue to sound even though the door is not
yet opened. Depending upon occupancy requirements the locked door mechanism
will not release and can remain engaged from 15 seconds to 90 seconds
or more after the panic device is pushed. Once the delay has been met
the door lock will allow egress and the alarm may continue to sound endlessly
or will shut off after the door is closed.
EVALUATION OF RESIDENTS
Sometimes elderly people become confused and disoriented when they leave
their personal residence and move to a retirement community. These residents
show signs of dementia from a change to their environment. In other cases,
long-term residents suddenly develop demented behaviors that are often
spontaneous and unknown to the staff. A confused resident that was previously
thought of as a person free to roam, now needs to be evaluated and potentially
transferred to a facility capable of more closely monitoring that person.
These facilities provide a different level of assisted living with more
close attention paid to each patient. Residents with a rapid decline in
awareness should not be kept in unrestricted resident facilities without
strict supervision. That requires the immediate involvement of a personal
caretaker or family member. It may take several weeks or months for a
facility of this type to observe a resident behaving inappropriately,
and concerned family members making routine visits should really see the
change in their relatives’ daily abilities long before the management
of these long term residential care properties recognizes a difference.
THE DIFFERENCE BETWEEN SR. ASSISTED LIVING & MEMORY CARE FACILITIES
In facilities that provide housing for dementia patients or memory care
residents there is a higher standard of responsibility to ensure the residents
whereabouts are more diligently monitored. The security equipment involved
in this type of facility requires a higher level of observation, integration
with the administration oversight, and staff awareness training.
There are different levels of elopement security prevention hardware, depending
upon the type of facility. The most basic level uses locks and manual
door closers to contain residents within certain areas. Generally, a ward
with many memory care patients has full time supervision from facility
staff. There may be a nursing station or office where medications are
dispensed and some level of remote camera oversight. These cameras are
usually limited to placement in hallways, dining rooms or common areas.
Cameras are not typically found in patient rooms to allow for personal
privacy. These basic safeguarded areas do not have constant patient monitoring.
In other facilities, there are systems installed that monitor the presence
of a patient wearing a charm or pendant. Sometimes these devices are worn
as an ankle bracelet where choking hazards are of concern. These systems
are proximity detectors that rely upon the RFID chips (radio frequency
identification) or radio transmitters embedded in the pendants or charms
worn by the residents. If the perimeter areas covered by these devices
are activated due to resident proximity, the receiver signals all the
door locks in the area to lock to prevent the resident wearing the pendant
egress. This local lock down is only overridden by an authorized code
entry from a staff member that disables the locking mechanism, if properly
operating. Due to the higher egress potential, the safety of the residents
is more closely monitored by the facility staff. In the event of a fire
or other life safety issue, staff members would be in place to attend
to and allow the residents with memory impairment to leave the building
or the system can be disabled as it is connected to the life safety system
of the building.
PSYCHIATRIC FACILITIES & HOLDING WARDS
Proper delayed egress panic devices are commonly found in most low security
psych wards. If a patient attempts to push the door to exit the area,
and the ward is within a typical hospital an audible alarm will be sounded,
and the door will not release. That is because the panic device on the
door is connected to the hospital’s life safety system and will
only allow egress in the event of a fire event. Generally, the local panic
alarm alerts the staff members that patients are attempting to leave,
then the staff members address the patients that are attempting to exit
the area and the patients are redirected away from the door.
MAGNETIC LOCKING DEVICES
In most psych wards magnetic locks are used to control the doors in addition
to the delayed egress panic devices. The magnetic locks must be appropriately
rated for patient control. There are various magnetic locks that have
specific force ratings which can withstand high opposing loads. These
mag locks need to be tested on a routine basis to confirm their operational
condition. When a patient in a psychiatric ward is violent due to drugs,
they can often exhibit superhuman strength to the point of overcoming
a deficiently operating or under rated magnetic lock. That is why the
correctly selected and maintained mag lock is important for patient protection.
Defective door functions and deferred frame conditions also create potential
elopement locations. Magnetic locks cannot always secure and overcome
defectively functioning or bent doors and frames. Routine maintenance
and facility oversight of all door systems is essential to protect these
openings from unauthorized egress.
LOW SECURITY PRISONS & INSTITUTIONAL HOLDING AREAS
Prison populations that are restricted in wards or interior spaces are
often located within zones of exterior security that would allow egress
from an area without the potential for elopement or escape. In most of
these facilities the prisoners are fully monitored and escorted by guards
that regulate and control the inmate location at all times. Most facilities
have a centralized guard station that continuously monitors the population
with cameras and other types of sensors.
This general design concept allows the inmate population to leave a building
while remaining within controlled surrounding enclosed walls or fencing.
If a life safety issue arises within a penal facility, control of the
prison population is usually well coordinated and can be adequately contained
within exterior surrounding walls or fences when a life safety issues
arises within the facility buildings. As most prisons have a centralized
guard station which continuously monitors the population with cameras
and other types of sensors, prison egress and elopement is significantly
controlled. Magnetic locking systems are commonplace and remote activation
from a control center is generally how the inmates gain access to various
areas including path of travel for life safety egress.
ACTUAL CASE EXAMPLES OF ELOPEMENT CLAIMS
- A 350 pound violent psych patient charged an egress door that had both
a panic device and magnetic locking system, broke the door frame on impact,
shattering the adjacent wall, and ran into the street where he was run
over by a passing vehicle. Upon my inspection, it was determined that
the wooden wall studs had been both dry rotted and infested with termites.
The magnetic lock had been improperly powered and was unable to withstand
the designed rating of 2500 pounds to oppose an impact.
An elderly Alzheimer’s patient eloped from a long-term care facility
due to an improperly installed proximity sensing system and is found dead
in a nearby alleyway.
This long-time resident was wearing an ankle bracelet that was battery
powered and required routine inspection of the transmitting power. The
facility had not inspected the device on her ankle for over 1 year prior
to this event.
Upon inspection it was determined that the transmitter worn by the resident
had failed to provide an adequate signal to the monitoring proximity control
device and did not cause any lock activation of the perimeter doors, which
resulted in the resident walking out of the door unnoticed. It was also
found that the proximity sensing device was missing several critical antenna
locations that would have detected even a low battery condition, so the
resident walked out the door unchallenged. There were both nursing station
video cameras and staff members working nearby that observed the event.
Since the doors did not lock when the decedent approached the doors, the
new and inexperienced staff members in the area did not think that she
was one of the confined residents in their care. The confused resident
simply walked out the front door and became lost and disoriented, falling
onto rubble, striking her head on a nearby trash container, and died as
a result of that trauma. Conclusion: Although it was determined that the attending staff did not
act properly, the installation of the elopement system was found to be
substandard and not per the manufacturers requirements. The elopement
system had been installed several years prior to this claim and the facility
was not performing appropriate tests or inspections of the system to determine
its’ condition or function. The facility had changed ownership since
the original purchase of the elopement equipment and did not have relevant
safety information, owner’s manuals, or other service contracts
with a professional service provider that would have provided ongoing
maintenance, needed upgrades, or repair of defective or missing components.
The facility acted below the industry standard of care and did not appropriately
test or maintain the equipment as is required.
A new resident becomes disoriented and confused with her surroundings and
leaves without attending staff knowing she has left the building:
This resident had just moved into this facility within the past month prior
to this elopement event. The facility was open to all residents to come
and go as they pleased. It was unknown to the staff that the resident
that left the facility had no awareness of her surroundings. The resident
believed that she was on vacation and went out an alarmed door to “see
the sights”. It was not until dinner time that it was discovered
that the relatively new resident was missing. The facility contacted the
family of the resident and a search was made. The confused resident was
found a few blocks away from the facility in good shape and without any
recognition that she was not on a European tour seeing the sights.
Mike Panish has been the retained legal expert on numerous elopement cases.
He has evaluated facilities for compliance with specific life safety and
ADA hardware installations. As a consulting expert, he has surveyed and
determined if specific facilities are functioning within the industry
recognized standard of care. He has been retained by plaintiff and defense
in many elopement legal claims and has provided his consulting services
to facilities wishing to evaluate and upgrade their existing elopement
Construction Systems and Hospital Door and Hardware Systems are two divisions
of Panish Construction. Those companies have provided quarterly inspections
to medical facilities, psychiatric hospitals, and penal institutions for
over 35 years. Mike is a legal expert witness for all door types, door
access, and hardware equipment. He has personally serviced and installed
all door hardware required to meet every level of security, and patient
and inmate protective devices.
More information about Mike Panish's experience with
healthcare & mental health facilities