Elopment Risk Form

[Adult Day Services Center/Program Name]

ELOPEMENT RISK ASSESSMENT

Client:   _____________________________________                                                    Date:     _________________

Check all that apply:

1.     Orientation:

 Alert                  Confused *    Disoriented *

 Oriented:       Time                  Place                 Person

2.     Behavior:

 Calm                  Combative    Agitated *

3.     Ambulation:

 Independent *             ( Walker   Cane)

 Wheel Chair                                     Self Propels in Wheel Chair *

4.     Exit Seeking Behaviors: *

 Attempts to leave Center alone and is not safe to do so

 Observed attempting to open doors

 Verbalizes, “I’m going home…”

 Observed attempting to leave Center

 Other __________________________________

5.     “At Risk” Status:

If participant scores on any starred (*) items in question 1, 2, or 3, AND any item in #4, they are to be considered at risk for elopement.

6.     Client is “At Risk” for Elopement

 Yes                      No

7.     If yes:

 Update Service Plan

 Designate Risk on Assignment Sheet

 Informed Family and Document

 Update Monitoring Plan

 Other ________________________

Social Worker / Nursing Signature: __________________________        Date: ________________

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Adult Day Care Facts

• Nearly 78 percent of adult day centers are operated on a nonprofit or public basis and the remaining 22 percent are for profit.¹
• 70 percent of adult day centers are affiliated with larger organizations such as home care, skilled nursing facilities, medical centers, or multi-purpose senior organizations.
• The average age of the adult day center care recipient is 72¹, and two-thirds of all adult day center care recipients are women.
• Thirty-five percent of the adult day center care recipients live with an adult child, 20% with a spouse, 18% in an institutional setting, 13% with parents or other relatives, while 11% live alone.¹
• Fifty-two percent of the adult day center care recipients using adult day services centers nationwide have some cognitive impairment.¹
• Daily fees for adult day services vary depending upon the services provided. The national average rate for adult day centers is $61 per day (includes 8-10 hours on average) compared to an average rate for home health aides of $19 per hour.²