An occupational therapist's perspective on patient elopement from nursing homes

Mrs. Kim was one of my first patients when I was a young occupational therapist. She was an 89 year old resident of the nursing home and lived there for the previous seven years. Prior to her admission she was living at home with the support of her only son. She had diagnoses including hypertension, chronic obstructive pulmonary disease, and Alzheimer's disease. She had a history of depression and severe anxiety.

Mrs. Kim was a known 'flight risk' and tried to leave the nursing home facility on several occasions. The nursing home responded appropriately by installing window limiters and door alarms. Out of an abundance of caution they also made sure that Mrs. Kim always had her identification bracelet and she had an alarm that would sound whenever she wandered outside of a designated perimeter around the nursing station.

Despite all of these precautions she still managed to find her way out of the facility on at least three occasions in the preceding seven years - which resulted in the firing of several staff for their lack of attention to the detailed plan that was put in place to keep her safe.

Having seen friends and co-workers fired over this 'high-maintenance' patient, many of the staff at the nursing home viewed her as a 'problem' and a 'burden.' Some of the direct care staff were thrilled at the prospect of the occupational therapist taking Mrs. Kim off of the unit for therapy because that meant that they wouldn't have total responsibility for her continued monitoring.

In addition to the elopement risk, Mrs. Kim's behaviors caused other difficulty on the unit. Despite her advanced age and some physical frailty she was still very mobile and active. She would frequently run into other patient's rooms, frantic and screaming, trying to pull them out of their beds. Although the nursing home's policy was to minimize use of restraints, there were times when the physician ordered both chemical and physical restraints with the intent of maintaining Mrs. Kim's safety as well as the safety of other patients on the unit.

Mrs. Kim's communication skills were severely impaired, generally limited to a fast paced string of syllables that no one could interpret. The staff thought that she might be sometimes speaking in her native Korean language. The nursing home arranged for a Korean interpreter to meet with her once and it was determined that she was not speaking in Korean.

The Activities Director noted that Mrs. Kim enjoyed watering plants, watching television, and that she used to participate in a weekly Bingo group several years ago. Even then she required moderate to maximal assistance but it was the last functional group activity that anyone at the nursing home remembers her being able to participate in.

I read Mrs. Kim's chart thoroughly before I went to get her, so I knew that she had a history of depression and anxiety and I knew about her elopement risk. During the evaluation she bolted away from me and headed straight for the facility's side door. Fortunately I was well-trained by my supervisor to know how to handle the situation - I followed the facility procedure, paged "Dr. Walker" to the 'B' unit which prompted the rest of the staff to converge on the area. I was able to catch up to her in the parking lot not far beyond the side door. Mrs. Kim was frightened, and scratching at my arms, trying to get away - but she eventually calmed and I was able to complete the rest of the assessments that needed to be done.

Although the social and medical history in the chart seemed relatively complete, I asked my supervisor if I could try to contact the son to talk to him about his mother. It wasn't part of the standard OT evaluation to contact family members but Mrs. Kim's lack of communication and the way she grabbed at my shirt made me want to find out more about her.

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I will never forget the son's explanation of his family's experiences as survivors from a civilian prison camp. When soldiers from Communist North Korea retreated from Taejon in 1950 they intended to leave no one alive from the camp. Although his father was executed, he and his mother survived - pretending to fall over dead as they were bound with wire to other members in their family who were strafed with machine gun fire in a mass execution.

Some years later the family emigrated to the United States, but the psychological scars never left. The son recounted a recurring nightmare that haunted his mother her entire life:

In her dream they were running. It didn’t matter where they had come from – but where they were going did. Forward. She pushed them ahead, as instinctively as breathing.

So many weeks, months, or years ago she would have needed his directive to move. Her husband taught her how to move forward, afraid of the day that he would no longer be with them. That day came a long time ago – so long ago that he was barely a distinct memory now. But his message was clear to her. Run! Run! His words roared in her ears; the muscles in her legs contracted, and she ran.

Thunderous shock waves buffeted them from all sides as they ran. Then on the horizon there was a flash of light: magnesium burning white light that lasted just a second. A column of earth and smoke plumed, mushrooming miles into the sky. She heard her son ask, “Is this the kind that we are not supposed to look at?” These were the final words that any of them would ever speak again.

Mortified, paralyzed, wondering how and why someone could hate someone so much to use such a weapon, and nodding to her son all at once, she made them run in the opposite direction.

Running didn’t matter, but she did not have time to realize this. Time and space instantaneously became irrelevant. In real terms they were incinerated immediately, but the moment in time was stretched out infinitely. Every horror that had driven their survival merged into a single event horizon. In the end, as she hallucinated that her children were drowning and melting into the Earth in front of her, hearing the horrible whir-chop of military helicopter blades as they ran, they all unmercifully died in a moment that lasted for an eternity.

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Ever since the son told me about his mother's experiences and nightmares, I never quite looked at patient elopement the same way.