Intake Forms- Elopement RISK ASSESSMENT July 18, 2011 By Maunalani Staff Name First Last RoomPhysicianDate of Assessment 1. Does resident have a court appointed legal guardian? Yes No 2. Does this resident have the cognitive impairment to make relevant decisions? Yes No 3. Does this resident have a history of escape or elopement? Yes No 4. Does the resident have a related diagnosis? (example, dementia, depression, mental illness, etc.) Yes No 5. Does the resident move around freely and independently with or without devices such as wheelchair, walker, etc? Yes No 6. Does the resident say that he/she wants to leave, to go home, etc.? Yes No 7a. Does the resident wander aimlessly? Yes No 7b. If yes, does the resident's wandering include risky behaviors such as trying to opening doors? Yes No 8. Are there relevant factors from resident's history? Consider elopement from previous home, history of leaving the premises unsupervised or without signing out, etc. Yes No 9. Does the resident exhibit behaviors such as restlessness and/or agitation? Yes No 10. Are there any factors (for example, recent loss or personal tragedy, anger), that may contribute to this resident's risk for elopement? Yes No Conclusion: Elopement Risk is: Low High If #3, #5, #6, #7 or #8 is yes=high risk for elopement If <3 or yes= low risk. If >3 high risk (1,2,4,9,10) If necessary, care plan approaches in progress note and service agreement. If high risk for elopement notify unit coordinator, and interdisciplinary team.SignatureDate
