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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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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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


  • 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.‚Äč
  • 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 protection systems.

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