Lost on Foot Silver Alert

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PURPOSE OF FACILITY TRAINING Lost on Foot Silver Alert Facility Training Manual To provide guidance to managers and staff of adult day care centers, assisted living facilities and skilled nursing

Describe two benefits of obtaining a quality diagnosis for a patient s symptoms of dementia Name two potential triggers for exit-seeking behavior.

1 PURPOSE OF FACILITY TRAINING Lost on Foot Silver Alert Facility Training Manual To provide guidance to managers and staff of adult day care centers, assisted living facilities and skilled nursing facilities regarding the scope of the lost on foot risk and mechanisms for minimizing these events. OBJECTIVES Name two aspects of the current scope of the lost on foot problem. Describe two benefits of obtaining a quality diagnosis for a patient s symptoms of dementia Name two potential triggers for exit-seeking behavior. Demonstrate validation (versus reality orientation ) as an effective means of communicating with an adult with Alzheimer s disease or related neurocognitive disorder. Name two benefits of validation. Name two additional communication techniques. COORDINATION & SUPPORT PROJECT TASK FORCE 211 Brevard County 211 Broward County 211 Palm Beach/Treasure Coast Agency for Health Care Administration Alzheimer s Community Care Broward Health North Carlin Rogers Consulting LLC Florida Assisted Living Association Florida Department of Children and Families Florida Department of Elder Affairs Florida Department of Law Enforcement Florida Highway Patrol Palm Beach County Sheriff s Office Plantation Police Department Nina M. Silverstein PhD SafetyNet by LoJack St. Lucie County Sheriff s Office Switchboard Miami, Inc. LOST ON FOOT SILVER ALERT GRANT Carol Waters, Silver Alert and Alzheimer s State Plan Coordinator, Department of Elder Affairs Administered by: Broward Health North Subcontractor: Alzheimer s Community Care 1 P a g e

2 FLORIDA SILVER ALERT HISTORY/BACKGROUND: On October 8, 2008, Governor Charlie Crist signed Executive Order enacting the Florida Silver Alert program which allows the immediate broadcast of information to the public regarding missing elders with dementia or other cognitive impairment, who are driving a vehicle or lost on foot. The Florida Silver Alert became state law during the 2011 state legislative session; the law is found in Florida Statutes and From October, 2008 through March, 2015, there have been 1,022 Silver Alerts issued for those missing in a vehicle. 1 Over 5 million Americans currently diagnosed with Alzheimer s disease. Number with Alzheimer s disease (AD) in Florida: 500, Persons with Alzheimer s disease who are cared for in the home = 70% % of people with Alzheimer s disease will wander away from a supervised setting at some point during the course of the disease. 4 Of those missing more than 72 hours, only 20% survive. 5 The first 6 hours of a reported lost person are the most critical, requiring law enforcement assistance to be found alive. 6 According to the Agency for Health Care Administration, there have been 446 elopements from assisted living and skilled nursing facilities in 2014 in Florida, and 505 in From January 9, 2012 to November 22, 2014, 66 residents eloped from Florida assisted living facilities. Twelve were deceased when found. 7 The Lost on Foot Silver Alert protocol facilitates rapid reporting of the missing person, and faster recovery. The Lost on Foot Silver Alert program will allow the people of Florida, as well as visitors to the Sunshine State, to help ensure the safety and security of vulnerable adults. 1 Florida Department of Law Enforcement (FDLE) 2 Florida Department of Elder Affairs (DOEA) 3 Lost and.found Alzheimer s Foundation of America, June, Missing Persons with Alzheimer s Disease, IACP National Law Enforcement Policy Center, Concepts and Issues Paper, April 2011, page 2 5 Alzheimer s Reading Room, Missing Persons with Alzheimer s disease, IACP National Law Enforcement Policy Center, page 2 7 Florida Department of Children and Families (DCF) 2 P a g e

3 RELATED NEUROCOGNITIVE DISORDERS: Lewy Body disease Frontal Temporal Lobe disorder ( Pick s disease ) Vascular dementia Huntington s disease Parkinson s disease (end stage) AIDS Syphilis (end stage) LOST ON FOOT SILVER ALERT CRITERIA: The following criteria determine the issuing of a Lost on Foot Silver Alert by law enforcement: The missing person is sixty (60) years of age or older and there is a clear indication that the individual has an irreversible deterioration of intellectual faculties (for example, Alzheimer s disease). This must be verified by law enforcement. OR The missing person is 18 to 59 years of age with an irreversible deterioration of intellectual faculties, verified by law enforcement. SILVER ALERT vs. LOST ON FOOT, SILVER ALERT The current Silver Alert program, signed into law in 2011, is designed to aid law enforcement in the rescue of persons with Alzheimer s disease or related neurocognitive disorder, who are driving a vehicle, by broadcasting important information to the public. The Lost on Foot Silver Alert protocol is designed to facilitate the rescue of persons with Alzheimer s disease or related neurocognitive disorders who have eloped from a supervised setting with family or friends, or from an adult day center, assisted living facility or skilled nursing home. Silver Alert legislation provides for law enforcement to share information about the missing person with local media outlets, other law enforcement agencies, the community, local Alzheimer s organizations, Aging and Disabled Resource Centers (ADRC s), Florida Department of Elder Affairs. 3 P a g e

4 IMMUNITY RE: HIPAA ( Health Information Portability and Accountability Act ) Pursuant to Florida Statute , this does NOT constitute a HIPAA violation: Upon receiving a request to record, report, transmit, display, or release information and photographs pertaining to a missing adult or missing child from the law enforcement agency having jurisdiction over the missing adult or missing child, the department, a state or local law enforcement agency, and the personnel of these agencies; any radio or television network, broadcaster, or other media representative; any dealer of communications services as defined in s ; or any agency, employee, individual, or person is immune from civil liability for damages for complying in good faith with the request to provide information and is presumed to have acted in good faith in recording, reporting, transmitting, displaying, or releasing information or photographs pertaining to the missing adult or missing child. RECOGNIZING THE RISK FOR INDIVIDUAL RESIDENTS/PATIENTS The risk of wandering and becoming Lost on Foot for a patient or resident with Alzheimer s disease is substantial! As above, 60-70% of patients WILL wander away from a supervised setting at some point in the course of the disease. If the patient/resident can walk or self-propel a wheelchair, he/she is at risk to become lost on foot. ***It is vital to view this risk as a matter of WHEN (not IF )*** The risk of elopement should be assessed for all new residents. Any resident able to walk independently or self-propel a wheelchair, is at risk to elope. The following questions are suggested by the National Council of Certified Dementia Practitioners 8 : Is the resident independently mobile? Is the resident cognitively intact? Does the resident have competent decision making capability? Does the resident wander? Does the resident have exit seeking behavior? Is there a past history of wandering or exiting a home or facility without the needed supervision? Does the resident accept their current residency in the facility? Does the resident verbalize a desire to leave? P a g e

5 Questions suggested by the national Council of Certified Dementia Practitioners, continued: Has the resident asked questions about the facility s rules about leaving the facility? Is there a special event/anniversary coming due that the resident normally would go to? Is the resident exhibiting restlessness and/or agitation? This risk assessment should be performed at preadmission (as the assessed risk may impact room selection within the facility), upon admission, and additionally relative to the assessed risk, and with any significant change in cognition and/or physical condition, new behaviors, etc. According to the National Council of Certified Dementia Practitioners (NCCDP), the first few weeks of admission, a change in diagnosis/condition, or a special event seem to be the higher risk time frames for elopement. 9 According to WeArePendulum, almost half of elopement cases and associated accidents occur within the first 48 hours of nursing home admission. 10 Facilities are encouraged to construct a risk assessment tool appropriate to their settings. The following page presents a suggested Elopement Risk Decision Tree Guidelines for Best Practices, Elopement, Risk Prevention and Management of Missing Residents, P a g e

6 FACILITY ELOPEMENT RISK ASSESSMENT DECISION TREE Resident Name: Unit/Room: Date: Resident is ambulatory or self-mobile in wheelchair? YES NO N STOP New admission who has made statements questioning the need to be here or, Resident is cognitively impaired, with poor decision-making skills, and/or pertinent diagnosis (e.g., diagnosis of Alzheimer s disease or related neurocognitive impairment) or has a BIMS score of < 12 or, Resident is alert but non-compliant with facility protocols regarding leaving the unit. YES NO STOP Resident has a history of wandering and/or elopement (either in the facility or elsewhere) or, Exit-seeks - opens, or attempts to open doors within the facility or to the outside, or, Makes statements about going home, or that they are leaving or seeking to find someone/something or, Resident takes medication(s) that may increase restlessness and/or agitation YES NO STOP Establish Care Plan for high risk for elopement residents identifying strategies for the cognitively intact vs. cognitively impaired individuals. Ensure that any and all medical/medication issues are evaluated and addressed Educate staff as to individualized risk, risk factors and care plan strategies Utilize wander detection/prevention systems appropriate to the facility Add the name and photo of the resident to the facility s alert process Re-evaluate all interventions at least quarterly and verify which residents continue at high risk and that their information is on the facility s alert documentation Notify security, reception desks, etc. forward resident information and photo Conduct elopement drills monthly and additionally as indicated Signature/title: Date: 6 P a g e

7 PREVENTIVE STRATEGIES I. Identify triggers specific to the patient/resident Fear, anxiety, agitation Change in staff caregiver Inability to locate bathroom, bedroom, activity ( day ) room, dining room Overstimulation noise, lights, many visitors Wanting to go to work, go to church, go home Relocation stress change in room, nursing unit, floor or wing Conflicts with other patients/residents II. Individualize plans of care with patient-specific behavioral interventions Identify favorite activities Provide opportunities for success and recognition (artwork, crafts, games, singing/dancing, etc.) based on social history Assign the resident a room away from exits Employ the appropriate wandering device III. Evaluate/treat relevant medical and/or medication issues IV. Disseminate photos/names of those at risk, to all manned exits V. Ensure that ALL facility staff are oriented to the risk of elopement in general, and to the specific individuals identifies as high risk VI. Elopement drills, recommended quarterly (and no less than semi-annually) 11, and additionally as indicated (i.e., for an actual or a near miss event). VII. Structure the process for manning exit doors in the event of a fire alarm (because locks will disengage automatically, facilitating exit-seeking behavior) VIII. Assign specific staff members to specific search areas, for example: Notify Administration upon initiation of search Security staff check the building s perimeter Housekeeping staff check common areas Certified Nursing Assistants search bedrooms/bathrooms/closets Nurses check offices, medication rooms, treatment rooms Dietary staff check dining rooms/pantries, etc. Activity staff check auditorium, craft rooms, meeting rooms, etc Guidelines for Best Practices, Elopement, Risk Prevention and Management of Missing Residents, P a g e

8 Call at the FIVE (5) minute mark* if the patient/resident is not found. *This FIVE minute time frame is the request of Law Enforcement! Continue facility search IX. Provide ALL staff with Level I and Level II training in Alzheimer s Disease and Related Disorders ( ADRD ). All staff members, regardless of department, play a role in safeguarding patients/residents from elopement when they understand the risks of wandering and elopement related to Alzheimer s disease and related neurocognitive disorders, and if knowledgeable of effective communication techniques and behavioral interventions. Provide periodic refreshers to staff about the risk of elopement, warning signs to report, and the facility s preventive measures. Ensure that staff understand elopement to be an issue of when versus if; encourage and reward vigilance. ADDRESSING BEHAVIORS Anxiety, agitation, restlessness Increased confusion, forgetfulness Combativeness, aggression Hallucinations, delusions, paranoia Wandering, pacing, exit-seeking The above behaviors may occur due to unmet needs: Fear (provide reassurance) Pain (possible illness or infection common are urinary tract infections and pneumonia) Hunger, thirst (show a snack or drink as the person may not be able to verbalize the need. If diabetic, the person may have low blood sugar) Need to toilet (consider toileting schedules for those who cannot express the need or selftoilet) Wearing uncomfortable clothing/shoes Medication side effects and/or interactions Proactively addressing patient s/resident s needs may reduce the incidence of challenging behaviors and wandering/exit-seeking. 8 P a g e

9 RECOMMENDED COMMUNICATION APPROACHES/TECHNIQUES: VALIDATION: (versus challenge or correcting) these persons will generally respond well when validated, treated with dignity and respect, and given ample time to respond to questions. Example person is pacing, appears agitated, says I need to get to work Hello, my name is John. What is your name? Tell me about your work. Where do you work? What do you do there?, etc. Speak to the person at eye level if they are sitting, sit or squat so that you are at eye level. Speak in a calm voice and slowly. Avoid touching the person or anything they are holding or wearing without first explaining what you are doing and asking permission to touch. Avoid approaching from behind. Keep extraneous noise/lights to a minimum. Give ample time for responses as it may take the person an extended period to process what you have said or asked. Give simple instructions, one small step at a time. Be prepared to DEMONSTRATE what you are asking the person to do for example, if you are asking the person to stand, pretend you are sitting and demonstrate standing up they may not remember what your words mean. CALLING There is no required waiting period before a person can make a missing person report. Families and facilities are encouraged to call within FIVE (5) minutes*, if their initial search did not locate the person, or immediately if they have not seen the person in FIVE (5) minutes or more. *Request of Law Enforcement! 9 P a g e

10 INFORMATION TO PROVIDE WHEN MAKING THE INITIAL REPORT TO 9-1-1: Full name or nickname? Which name is he/she most likely to respond to? Age, physical description, photo (scars, tattoos, etc.) Photograph Language of origin and language most likely to respond to Relationship of reporter to the missing person Time/place of last known location Clothing worn Results of initial search by the facility History of similar events? if yes, where was the person found? Current medical conditions and medications is the person at risk for a medical emergency if a dose is missed? Is the person wearing medical alert jewelry or an electronic locator device? Which door or window did the person leave from? Are there familiar locations nearby? church? former workplace? favorite coffee shop? Would the missing person be drawn to a nearby landmark? Is the missing person fearful of, or dislike crowds? Is the missing person likely to walk toward or away from the sun? away from or toward water? Does the person have a close friend or confidant who might be able to provide information on possible whereabouts (perhaps based on prior conversations with the person)? 10 P a g e

11 DOCUMENTATION OF ELOPEMENT EVENTS Preventive strategies are also facilitated by thorough documentation of elopement attempts or actual elopements: Identified triggers for the elopement episode Where and how the person was found Interventions that were used to return the person to the facility Findings of the assessment of the person upon return to the facility and any care/treatment rendered Notifications: to law enforcement, to physician, to family, etc. New or changed physician orders New or changed care plan approaches/preventive strategies Incident report per facility policy/procedure ELOPEMENT DRILLS Drills on a regular basis are recommended (as above, recommended quarterly, or at least semi-annually Document the results of each drill o Time person was noticed to be missing o Time law enforcement was called o Number of staff participating in drill o Adequacy of staff response to the missing person alert did staff response follow established policies/procedures? Reeducate staff based on the results of the drill Proactive drills keep the risk of elopement prominent and facilitate proper response in a real elopement event The following page presents a suggested format for documentation of elopement drills 11 P a g e

12 Suggested Elopement Drill Form Date Drill Conducted: Time Drill Conducted: ( Time person noted to be missing ) Search Areas Outdoor Areas Common Areas Resident Rooms Activity/ Day Room Meeting/Training Rooms Bathrooms/Shower Rooms Dining Rooms Kitchens Stairwells Other: Staff/Department Assigned to Each Search Area Was facility administration notified promptly? [ ]Yes [ ]No-explain: Was resident found? [ ]Yes [ ]No* *Time called: (should be at the FIVE [5] minute mark if resident is not found) Did staff respond immediately to their search assignments? [ ]Yes [ ]No-explain: Re-training needed? [ ]No [ ]Yes-describe: Facility Administrator Signature/Title 12 P a g e Date:

13 BIBLIOGRAPHY/REFERENCES Florida Statutes - Chapter 937, Florida Statutes: Missing Person Investigations Executive Order of the Governor # FDLE Silver Alert Plan Silver Alert Support Committee Model Policy International Association of Chiefs of Police, 2010 Training Key #648 - International Association of Chiefs of Police, 2010 International Assoc. of Chiefs of Police, Alzheimer s Initiatives, Missing Persons with Alzheimer s Disease, IACP National Law Enforcement Policy Center, Concepts and Issues, Paper, April 2011 Lost and. FOUND Alzheimer s Foundation of America, June, 2012 FBI: Awareness of Alzheimer s Disease, October, 2011 Lantana, Florida Police Department-Missing Persons, SOP #18.07 Elopement Manual, Guidelines for Best Practice, Dementia and Wandering Behavior, Nina M. Silverstein, Gerald Flaherty, Terri S. Tobin, Springer Publishing Company, Inc., P a g e

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