Washington State Department of
Health
Division of Environmental Health
Office of Drinking Water
Elopement and Wandering, Safety Risk
Assessments, and the Built Environment
CONSTRUCTION REVIEW SERVICES
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Objectives
• Challenges of wandering and elopement
• Familiarity with regulatory environment
• Recommended practices
• Building and Design options
• CRS Introduction and Rules Update
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Elopement
When a patient or resident who is
physically or mentally and/or chemically
impaired wanders, walks, or runs away,
escapes, or otherwise leaves a caregiving
facility or environment unsupervised,
unnoticed, and/or prior to their scheduled
discharge.
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Wandering
“syndrome of dementia related locomotion
behavior having a frequent, repetitive,
temporally-disordered and/or spatiallydisoriented nature that is manifested in
lapping, random, and/or pacing patterns,
some of which are associated with eloping,
eloping attempts, or getting lost unless
accompanied” Alagase, D.L.et al, 2009.
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Shared Risks
Elopement
Successful
Exiting
Wandering
Behavior
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Why terms matter:
• Common language

Accurate communication of risk
• Consistency in reporting
• Accurate logs
Washington State Department of
CONSTRUCTION REVIEW SERVICES
Health
Division of Environmental Health
Office of Drinking Water
Hospital Elopement Survey Data
9%
10%
11%
0 Elopements
1 to 50 Elopements
50 to 300 Elopements
No Response
70%
Washington State Department of
Health
Division of Environmental Health
Office of Drinking Water
American Society for Health
Care Engineering, 2013
Advocacy Report
CONSTRUCTION REVIEW SERVICES
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Regulatory Environment
• WAC 246-320-146 Adverse health events
and incident reporting system
• DOH must be notified of patient death or
serious disability associated with patient
elopement (disappearance)
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
DOH (Reactive) Inquiry:
• Patient competency
• Safety of the environment of care
• Adequate staff
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
DOH (Proactive) Plan Review
• WAC 246-320-505
• 2010 FGI Guidelines: Section 1.2-4
 Patient Safety Risk Assessment (PSRA)
o Appendix material
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
2010 FGI PSRA
• Early in the project
• Interdisciplinary
• Identify hazards
• Develop & implement mitigations
• Appendix material
• Facility P/P are default
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
2014 FGI Safety Risk Assessment (SRA)
• Requirement
• Interdisciplinary
• Documented assessment ‘Process’
• Identify hazards and potential risks (and the
underlying conditions)
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
2014 FGI Safety Risk Assessment (SRA)
• Evaluate Hazards & Risks
• Report Up
• Identify contributing design features
• Identify mitigating measures
• Incorporate mitigations and document
implementation to completion
Washington State Department of
Health
Division of Environmental Health
Office of Drinking Water
2014 SRA
Required
CONSTRUCTION REVIEW SERVICES
Washington State Department of
Health
Division of Environmental Health
Office of Drinking Water
CONSTRUCTION REVIEW SERVICES
Washington State Department of
Health
Division of Environmental Health
Office of Drinking Water
CONSTRUCTION REVIEW SERVICES
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
www.breakthrough-hq.com
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
PSRA and SRA Summary
• 2010 FGI Guidelines: Section 1.2-4

Patient Safety Risk Assessment

Appendix material
• 2014 FGI Guidelines Section 1.2-3

Safety Risk Assessment

Required
Washington State Department of
CONSTRUCTION REVIEW SERVICES
Health
Division of Environmental Health
Office of Drinking Water
Identify
Respond
Manage
Wandering and Elopement Programs
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Risk Reduction
Policy
Design
People
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Risk Reduction
• Direct supervision
• Chain of care considerations
• Special waiting areas
• Room or floor designation / location
• Room door coding
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Risk Reduction
• Color coding systems

Gown, wrist band, slippers
• Alarms: bed, chair, door etc.
• High tech options

RFID, pendant systems
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Managing Wandering
• Reduce agitation
• Awareness of medication
• Activities
• Monitoring during shift change
• Engage the family
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Built Environment
•
•
•
•
•
•
Secured outdoor spaces
Ambulation paths
Open floor/activity spaces
Staff station at exits
Alarmed exit doors
Specialty egress doors
Washington State Department of
Health
Division of Environmental Health
Office of Drinking Water
Example:
• Secured outdoor area
• Ambulation path
• Activity Areas
• Staffed exit
• Delayed egress
CONSTRUCTION REVIEW SERVICES
Washington State Department of
Health
Division of Environmental Health
Office of Drinking Water
CONSTRUCTION REVIEW SERVICES
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
• Room location
• Pendant system
• NS location
• Identify At-risk
residents
• Security camera
system
• Separate
Floor or Unit
Physical
Security
Environment
of Care
• Staff Training:
Building
People &
Policy
• Chain of
Care
• Engage
the family
• Staff Training:
Policies
• Specialty Doors
• Separation of suite
from exit corridor(s)
• Direct Supervision
• Special robe color
• System Tests
• Identify types of wandering
and elopement risk
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
International Association
for Healthcare Security and
Safety: 2012 Security
Guidelines for Healthcare
Facilities
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Process Reminder
Develop operational and physical
approach (CRS Tech Assist)
CRS review of planned
modifications
Implement and integrate new
elements in your system
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Design and Construction Challenges
• Existing construction
• Familiarity with codes
• Maintaining the means of egress
• Resident / patient rights
• Mixed populations
• Over-reliance on devices
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Challenges:
Existing construction
• Patient rooms required to
have window to the
outside
• Common circulation paths
• Exits (appropriately)
located remotely and on
perimeter
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Drawing space for challenging existing conditions
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
• Room location
• Pendant system
• NS location
• Identify At-risk
residents
• Security camera
system
• Separate
Floor or Unit
Physical
Security
Environment
of Care
• Staff Training:
Building
People &
Policy
• Chain of
Care
• Engage
the family
• Staff Training:
Policies
• Specialty Doors
• Separation of suite
from exit corridor(s)
• Direct Supervision
• Special robe color
• System Tests
• Identify types of wandering
and elopement risk
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Talking Walls Murals
Washington State Department of
Health
Division of Environmental Health
Office of Drinking Water
CONSTRUCTION REVIEW SERVICES
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Risk Reduction
Door Hardware
and Special Locking
Arrangements
Oddly Specific – Funny Signs
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Specialty Door Hardware:
Delayed Egress
Secured
WAC 388-78A
Assisted Living
WAC 388-97
Nursing Home
2000 Life
Safety Code
Section 2380
Section 2920
Exceptions
to 18.2.2.2.4
Section 2920
Exceptions
to 18.2.2.2.2
and 18.2.2.2.4
Section 2380
2012 International
Building Code
1008.1.9.7
State
Amendments to
1008.1.9.6
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
2000 LSC Section 18.2.2.2.2
Patient Sleeping Room Doors
Exception #1
• Control access to room from corridor
• Operable only by staff
• Does not restrict egress from room
Exception #2
• Where required by clinical needs
• Key carried by staff at all times
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
2000 LSC Section 18.2.2.2.4
Doors in the means of egress
Exception #1
• Locks without delayed egress
• Clinical need for special security
• Staff can readily unlock at all times
Exception #2
• Allows one delayed egress lock in
means of egress path
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
2012 IBC Section 1008.1.9.3
Locks and Latches
• Allows locking arrangements in non
healthcare occupancies with ‘places
of detention or restraint’.
• Conditions / supplemental systems
are required
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
2012 IBC Section 1008.1.9.6
Special Locking in Group I-2
with State Amendment
• Allows approved special egress locks,
with conditions
• Special provisions for psychiatric
treatment by amendment
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
2012 IBC Section 1008.1.9.7
Delayed egress locks
• Approved, listed, delayed egress locks are
allowed in occupancies other than A, E
and H with conditions
• Occupant shall not be required to pass
through more than one door with
delayed egress lock before entering an
exit
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Changes to CMS Survey
& Certification
CMS S&C 13-58-LSC
Letter dated August 30th,
2013
CMS S&C 12-21-LSC
Letter dated March 9,
2012
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
CMS Categorical Waivers
• Identified in entry interview
• Must meet the specific requirements in
2012 LSC the general requirements of
the 2000 LSC
“only if the provider / supplier is in compliance
with all other applicable provisions”
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
2012 LSC
Sections 18.2.2.2.2 – 18.2.2.2.6
18.2.2.2.5.1 and 18.2.2.2.5.2 allow door
locking arrangements
• Where clinical need requires security
• Where patients require special security
• Where patients pose a security threat
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
2012 LSC
Sections 18.2.2.2.2 – 18.2.2.2.6
• 18.2.2.2.4 allows delayed egress locks
complying with 7.2.1.6.1
• 7.2.1.6.1 does not limit the number of
delayed egress locks in the means of egress
• Supporting criteria / conditions
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
2015 IBC: Specialty Door Hardware
• Controlled Egress
• Expanded to I-1 and I-2
• Delayed Egress
• Can have two delayed
egress doors if total delay
is less than 30 seconds.
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Review of Building Modifications
Develop an operational and physical
approach (CRS Technical Assist)
Apply to CRS for review of planned
modifications
Implement and integrate new
elements into the care model
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
• At-risk residents
• Defined Terms
• Keep policies
current
• Keep staff
current
• Mitigate Risk
• People, Policy,
and Building
Assess
Manage
Improve
Respond
•Practice and
Document
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Challenges and Opportunities
• Existing Construction
• Building / Licensing Codes
• Form (should) follow function
• Recognize limitations of the building
• Realize operational solutions first
• CRS is a life safety / code resource
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Key Points
• Elopement deserves attention
• Communications and assessments primary
contributors to elopement incidents
• Preventive measures appropriate to risk
• Ensure a quick and thorough response
• People, Policy, then Building
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Questions?
& Thank You
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
CRS
360-236-2944
Facility Type
Hospital
Boarding Home
Nursing Home
Region 1
Region 2
Region 3
Region 4
Janet Smoot
Region 5
Region 6
Mina Zarelli
Matthew Campbell
Susan Upton
Mina Zarelli
Clynn Wilkinson
Allen Spaulding
Selected projects for above facility types
Kevin Scarlett
Cherry Harvest Camp
Correctional Facility (Infirmary)
Food Service
State Facility (Institution)
Temporary Worker Housing
Stan Iwagoshi
Child Birth Center
End Stage Renal Disease
Mobile Unit
Matthew Campbell
Alcohol & Chemical Dependency Hospital (private)
Ambulatory Surgery Facility (non-hospital based)
Steve Pennington
Hospice Care Center
Psychiatric Hospital (private)
Residential Treatment Facility
Clynn Wilkinson
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Source and Credits
• 2014 Alzheimer’s Disease Facts and Figures
• Alzheimer’s Association: Dementia Care
Practice Recommendations for Assisted
Living Residences and Nursing Homes
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Source and Credits
• National Council of Certified Dementia
Practitioners
• Elopement Manual
• Facilities Guidelines Institute
• Update Series: Designing for Safety
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Source and Credits
• Dec. 2007 AHRQ WebM&M Spotlight Case
• Commentary: Debra Gerardi, RN, MPH, JD
• Wandering in Hospitalized Older Adults
American Journal of Nursing (try this:
series) October 2008 Vol 108, No.10
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Construction Review Services
Washington State Department of
CONSTRUCTION REVIEW SERVICES
Health
Division of Environmental Health
Office of Drinking Water
People
Building
*
*
Process
Environment of Care
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
Hospital Licensing
Regulations
• WAC 246-320
•
Construction
Standards only
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
CMS Conditions of
Participation
• In the process of
adopting:
• 2012 LSC
• 2012 NFPA 99
Washington State Department of
Health
CONSTRUCTION REVIEW SERVICES
Division of Environmental Health
Office of Drinking Water
State Building Codes
• In the process of
adopting the
International family
of codes; IBC, IFC,
IMC, UPC…