elopement assessment screen page 3

							ELOPEMENT ASSESSMENT SCREEN
Score 1 point for each YES answer
                                                                         NA/AR/CO   Q1        Q2             Q3
Score of 5 or > = Wanderer/High Risk Potential
1. Is resident Ambulatory
   (G-1; c, & d, (A) = 0, 1, or 2                                         Yes/No     Yes/No    Yes/No         Yes/No

2. Does resident have a habit of wandering?
   (E; 4, a (A) = 1, 2, or 3)                                             Yes/No    Yes/No    Yes/No          Yes/No

3. Does resident have a habit of pacing?
   (E-n = 1 or 2)                                                         Yes/ No   Yes/No    Yes/No          Yes/No

4. Does residnet express anger at Nursing
   Home Placement? (E-d = 1 or 2)                                         Yes/No    Yes/No    Yes/No          Yes/No

5. Does resident verbalize comments such as
   " I'm going home"?                                                     Yes/No    Yes/No    Yes/No          Yes/No

6. Does resident have a history of Alzheimer's,
   Dementia, or a Psychiatric History?                                    Yes/No    Yes/No    Yes/No          Yes/No
   (I-q, u, dd/cc/ee/ff, or gg checked off on MDS)

7. Has resident ever eloped before?
                                                                         Yes/No      Yes/No    Yes/No         Yes/No
8. Has the family ever commented that the
   resident has had wandering tendencies?                                Yes/No     Yes/No    Yes/No         Yes/No

9. Does resident have any unsettled
   relationships? (F-2: any areas checked)                                Yes/No    Yes/No    Yes/No         Yes/No

(Score 1 point for each YES answer)
TOTAL POINTS FROM THE ABOVE=

*** If resident attempts an Elopement, complete a new assessment and give copy to :
                                                                                              DON ___________
                                                                                              MDS/CP ________

Nurse:                                                                                                       Date:
Resident:                                                   Physician:                                       Rm:

*New Admissions/Annual Review/Change of Status Assessment




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