Maine DHHS Scrutinized for Lax Oversight of Nursing Home Elopement Amid National Regulatory Crackdown

The Maine Department of Health and Human Services (DHHS) has come under scrutiny for its oversight of nursing facilities, particularly regarding incidents of resident elopement – a problem that continues to impact facilities across the nation.

Judging by Maine’s example, elopement is a tricky problem to tackle, and existence of tough regulation alone isn’t addressing it. In addition, the Maine Monitor reports that despite the increasing number of such incidents, the DHHS rarely conducts thorough investigations or imposes sanctions.

Meanwhile, enough elopement incidents occur each year nationally, resulting in headaches and sometimes serious trouble for long-term care facilities. The Washington Post published a report in December analyzing inspection records of facilities dating back to 2018 to discover that since then, more than 2,000 people have wandered away from assisted-living and dementia-care units or been left unattended outside, with nearly 100 people dying.


In Maine, from 2020 to 2022, at least 115 elopement incidents were reported in 48 residential care facilities classified as Level IV, which are similar to assisted living facilities in other states, the report states. However, the majority of these incidents were met with minimal investigation, often limited to desk reviews. In 98 out of 115 reported elopement cases, the state conducted only desk reviews or no investigation at all, and sanctions were seldom imposed.

According to the Monitor, 30 incidents involved facilities housing residents with severe dementia, which are required to have secured environments to prevent such occurrences. Despite these requirements, the Monitor found that only two facilities faced sanctions for elopement incidents during the specified period.

In these cases, the DHHS only mandated plans of correction without imposing fines or conditional licenses.


Both providers and advocates have criticized the state’s staffing requirements and dementia training as inadequate. Non-memory-care facilities have no mandatory dementia training, and memory care facilities only require one-time training. Some facilities voluntarily exceed state staffing requirements to ensure resident safety, but many providers struggle to meet these standards due to resource constraints.

Skilled Nursing News has reported that nationally operators are struggling with stricter regulations and penalties related to resident elopement, and even with the growing severity of rules the problem remains, not withstanding citations for facilities.

“I had a woman open the window,” Fran Kirley, CEO of Nexion Health, which operates skilled nursing facilities across Texas, Mississippi, and Louisiana, told SNN. “She was ambulatory, cognitive. She opened the window, got out of the building, and went down the street. We found her 20 minutes later. [Surveyors] gave me the immediate jeopardy for that. And I said, what could I have done differently?”

Still, some operators say the definition of elopement may need to be redefined – and issuing plans of correction without fines is a more constructive way to address the problem.

Rick Forscutt, CEO of Dallas-based Priority Management, told SNN that his company has also been grappling with how to respond to elopement.

“When it comes to elopement, the interpretation and enforcement of the regulations can sometimes feel challenging,” Forscutt said. “For example, we’ve had situations where a resident opens the door for another resident who then briefly steps out of the premises. The resident who walked out had a wander guard bracelet on, and the wander guard system alerted us. However, another staff member happened to be in the parking lot, saw the resident, and immediately brought them back inside the facility.”

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