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What can we learn?

Aged care residents who go missing: What can we learn from compulsory reports?

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From the Office of Aged Care Quality and Compliance
(Aged Care Complaints Scheme)

About this report

Who is this report for?

All Australian Government subsidised aged care providers.

What is a ‘What can we learn?’ report?

What can we learn? reports provide an in-depth analysis of data on a specific topic; identify possible risk factors related to the topic; and outline suggestions of areas that aged care providers may wish to review within their service. These reports are not advice or directions.

Topic: Compulsory reports of residents who go missing

The data presented in this report includes an analysis of missing resident data recorded by the Scheme from 1 January 2009 to 30 June 2009, and the following financial year, 1 July 2009 to 30 June 2010.

Background

Since 1 January 2009, all approved providers of residential aged care services have been required to report to the Department of Health and Ageing (the department) when a resident is absent without explanation from a residential aged care service (referred to as a missing resident) and the police have been notified. Specifically, a report must be made to the department within 24 hours of the absence being reported to police. A report must also be made to the Department if a missing person is returned by police prior to the service being aware that the resident is missing.

Reducing the incidence of residents going missing from residential aged care services is a complex matter. Under the User Rights Principles 1997, approved providers need to balance supporting residents' rights to freedom and quality of life with ensuring the safety of residents. In addition, the Aged Care Accreditation Standards require approved providers to ensure that optimum levels of mobility and dexterity are achieved for all residents and that residents are assisted to achieve maximum independence.

• The purpose of compulsory reporting of missing residents is to:
• ensure prompt and appropriate action is taken to find the missing resident
• ensure the person and other residents in the service are safe
• assist the service to identify improvement areas to ensure resident safety, and
• use the data to inform the wider aged care industry of trends.

The department publishes the total number of missing resident reports it receives through the Report on the Operation of the Aged Care Act 1997 (ROACA).

Residents reported missing from a service without explanation

Since compulsory reporting started on 1 January 2009, the number of missing resident reports was:

• 363 reports from 1 January 2009 to 30 June 2009 (6-month period).
• 744 reports from 1 July 2009 to 30 June 2010 (12-month period).

All analysis for this report is based on these figures.

All information analysed in this report is from self-reported administered records which are potentially subject to data entry error and defined reporting requirements.

The department has initiated a number of processes to improve the department’s record keeping and data integrity to strengthen the reliability and validity of data used for future analysis.

Note: These vary from the data published in ROACA (367 reports for 2009 and 745 reports for 2009-10). The figures were revised after in-depth analysis was undertaken for this report.
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Incident circumstances

How did the resident leave?

Some reports included details about how the resident left their residential aged care service. The common themes were:

• The resident left the facility on social outings with family or friends without notifying staff of where they were going or if they were going to return late.
• A visitor, staff member or another resident unintentionally helped the resident to leave, for example when they exited a secured area or (less frequently) when the resident followed them as they were leaving the service.
• The resident wandered during staff-supervised activities outside of the service.
• The resident left through unlocked doors, gates or windows, including by learning the security keypad door codes.

Timeframes for finding missing residents

• Nearly 90 per cent of missing residents were found within 24 hours.
  • The proportion of residents found within three hours increased from 30 per cent in the first 6-month reporting period to 40 per cent in the following 12-month reporting period.
• On average, over 70 per cent of missing resident reports indicated a police search was involved in attempting to locate a missing resident.
  • The proportion of reported police searches for missing residents increased from 59 per cent in the first 6-month reporting period to 86 per cent in the following 12-month reporting period. In some cases, missing residents were located by other persons (see ‘Who found missing residents?’).

	1 January 2009–30 June 2009			1 July 2009–30 June 2010
	Yes	No	Unknown	Yes	No	Unknown
Found within 24 hours	88.7%	7.4%	3.9%	89.2%	6.0%	4.7%
Found within three hours	29.5%			40.2%
Police search	58.7%	41.3%	-	85.9%	12.1%	2.0%

Who found missing residents?

• The police found approximately one in three missing residents.
• The public, family and friends found approximately a third of missing residents.
• On average, 16 per cent of missing residents were found by staff of the service.
• On average, 11 per cent of residents returned of their own.

	1 January 2009–30 June 2009	1 July 2009–30 June 2010
Family	10.5%	9.8%
Friend	2.2%	1.1%
Police	32.0%	34.5%
Public	23.7%	22.4%
Self return	9.9%	12.9%
Staff from service	18.5%	14.0%
Unknown	3.3%	5.3%

Missing resident profile

• Over 80 per cent of missing resident reports involved a resident with some form of cognitive impairment.
• Approximately one in three missing resident reports involved a resident with a history of wandering.
  • The proportion of missing residents reported as having a history of wandering increased from 26 per cent in the first 6-month reporting period to 34 per cent in the following 12-month reporting period.
• Approximately one in six missing resident reports involved residents that were new entrants (within one month of entering the service).
  • The proportion of missing residents reported as being new entrants increased from 11 per cent in the first 6-month reporting period to 20 per cent in the following 12-month reporting period.
• More than 10 per cent of missing resident reports involved residents in respite care.
  • Respite care recipients represented 2 per cent of the Australian aged care population in the 2008-09 financial year. This suggests that respite care residents may be more at-risk of going missing as a proportion of the total aged care population.
• Approximately one in three missing resident reports involved residents leaving a secure environment.
  • The proportion of missing residents reported as leaving a secure environment decreased from 34 per cent in the first 6-month reporting period to 23 per cent in the following 12-month reporting period.

The table below presents information that was reported about the residents who went missing without explanation.

Resident details	1 January 2009–30 June 2009			1 July 2009–30 June 2010
	Yes	No	Unknown	Yes	No	Unknown
Cognitively impaired	81.5%	18.5%	-	80.4%	19.4%	0.3%
History of wandering	26.2%	63.4%	10.5%	37.4%	49.2%	13.4%
New entrant1	11.3%	88.7%	-	19.5%	71.8%	8.8%
Respite2	12.1%	87.1%	0.8%	11.0%	83.3%	5.6%
Secure environment3	34.2%	65.6%	0.3%	23.4%	61.8%	14.8%

Age profile

• In the 12-month reporting period, the majority of reported missing residents were in the 80-89 year age group. This is consistent with the majority of the residential aged care population being in this age group.
• However, the age group spread for reported missing residents was skewed towards younger ages encompassing 60 to 89 years.
  • This is most likely due to the reduced mobility of older residents aged 90 years plus and likelihood that younger aged care residents are physically able to walk independently.
• Virtually all of the reported missing residents aged less than 70 years presented as cognitively impaired.

1 July 2009–30 June 20104
Age group (in years)	Missing residents missing of residential aged care services			% total residential aged care population5
	% total reports	% cognitively impaired	% not cognitively impaired
40-49	1.9%	1.8%	0.1%	0.4%
50-59	8.2%	8.2%	-	1.6%
60-69	13.2%	13.2%	-	5.2%
70-79	26.1%	15.5%	10.6%	16.2%
80-89	41.9%	34.3%	7.4*	48.8%
90-99	8.6%	7.4%	1.2%	26.6%
100-109	0.1%	0.1%	-	1.1%

1. New entrants are residents that are within one month of entering a service.
2. Respite care is substitute care that can be arranged for planned breaks, regular weekly breaks, short holidays, or for emergency situations such as family illness.
3. A secure environment is one in which access in or out of the building is restricted. This may be through the use of physical devices such as code accessed doors.
4. Resident ages were only analysed for the 12-month period.
5. Permanent residential aged care does not include respite care.
6. New entrants are residents that are within one month of entering a service.
* An additional 0.2% is unknown.

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Wandering and secure environments

• In the 6-month reporting period, 16 per cent of missing residents had a history of wandering and were not in a secure environment and in the 12-month reporting period, 20 per cent of missing residents had a history of wandering and were not in a secure environment.
• It is important to note that:
  • that residents have a right to freedom to come and go as they please.
    • services can use a number of strategies (such as alert bracelets, secure environments and resident monitoring) to ensure that residents are safe.
    • These strategies can be influenced by input of family members or persons who are significant to the resident.

Profile of missing residents that were new entrants 6 to residential aged care services
	1 January 2009–30 June 2009		1 July 2009–30 June 2010
	Yes	No	Yes	No
Cognitively impaired	75.6%	24.4%	85.5%	14.5%
Missing on first day of entry	NA	NA	23.4%	76.6%

What can we learn from this data?

Overall, residents reported as absent without explanation are found quickly; nearly 90 per cent within 24 hours and an increasing number within three hours suggesting more effective techniques to locate missing residents may have been adopted since 1 July 2009. Importantly, the police, the public, family and friends play a major role in locating missing residents.

Risk factors

The information in this report indicates there are multiple risk factors that contribute to the likelihood that a resident may go missing. These include where they have:

• a cognitive impairment
• a history of wandering
• recently entered a service
• been receiving respite care in a service.

The common theme of these risk factors is a behavioural element. Residents may be confused or challenged by unfamiliarity in their environment due to a change of location or a cognitive impairment.

In addition, a combination of elements can increase the likelihood a resident can go missing. These factors include:

• residents who are able to walk independently and are cognitively impaired
• residents with a history of wandering that are not in a secure environment
• residents that are new entrants and are cognitively impaired.

There was an increase in the proportion of missing residents reported as having a history of wandering and/or being new entrants from the first reporting period (1 January 2009 – 30 June 2009) to the second reporting period (1 July 2009 – 30 June 2010). It is unclear whether this indicates that the number of residents that wander and that are new entrants has increased or simply that approved providers have improved their assessment, records, and/or reporting of these cases.
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How could risks be addressed?

At entry

Close monitoring and assessment of residents following entry, especially on their first day of entry, may reduce the incidence of residents leaving a service unnoticed.

At the point of entry, an individualised, person-centred approach to the orientation and integration of a resident into a new environment may minimise the distress and disorientation associated with entering into a residential aged care service and reduce the desire for residents to leave the service.

This may involve family members or persons who are significant to the resident that can provide support to the resident and assist in ensuring that important risk factors are identified when the approved provider is developing a detailed care plan and management strategy.

Pre-assessment of permanent and respite residents entering a service

Screening new residents (including those in respite care) and assessing their care needs on the day they enter a service may assist approved providers to manage the risks factors associated with residents going missing during their initial stay in a service. This can be done in tandem with other assessments.

Ongoing monitoring

Residents’ care needs change over time. Ongoing monitoring of care needs may be beneficial in managing risks associated with residents going missing. Ongoing monitoring is particularly important when risk indicators such as a history of wandering are identified.

Caregiver and community education

Increased community and aged care staff awareness could prevent some instances of residents going missing.

Aged care staff and the community play a critical role in ensuring the safety of residents, especially those who are at risk of going missing.

Providing appropriate education to care givers and the community can:

• increase their understanding of behaviours that may lead to a resident going missing
• prevent some incidents where people have unintentionally assisted a resident to leave or have not informed the service a resident has left.

In addition, education of the family or significant persons can assist in the development of effective resident care plans.

Through increased vigilance, anyone who visits a service can ensure that security measures are effective in residential aged care facilities. Care givers can accurately document resident movements out of the service and ensure they are returned to services on time.

The ‘Clinical perspectives’ attachment to this report provides a guide to understanding and managing wandering behaviour. Please refer to this attachment for further information on interventions to reduce wandering behaviours.

Interventions

Aged care services can intervene in a number of ways to reduce the possibility of residents going missing without explanation. This can include environmental modifications, technology and safety monitoring, and physical and psychological activities.

The environment around a service may also pose risks to missing residents, such as a service’s proximity to bushland, bodies of water, or roads.

Interventions should be based on a case-by-case analysis of potential risk factors that apply to individuals and the service’s location.

Interventions may be particularly useful in managing the risks associated with cognitively impaired residents or residents who exhibit wandering behaviour. More information about this can be found in the attached ‘Clinical perspectives’.

Conclusion

This report identifies a number of potential risk factors related to missing residents that have a behavioural element. Risk factors include cognitive impairment, a history of wandering, and residents entering an unfamiliar environment as a new entrant or for respite care.

Screening and assessment of the resident at the point of entry and education of caregivers and the community could reduce the likelihood of at-risk residents going missing.

There are a number of strategies that the industry could consider to manage and reduce the possibility a resident going missing without explanation, including environmental modifications, technology and safety monitoring, and physical and psychological activities.
As noted in the background, reducing the incidence of residents going missing is a complex matter. Under the User Rights Principles 1997, approved providers need to balance supporting residents’ rights to freedom and quality of life with ensuring the safety of residents.

The department is implementing improvements in the current practice of gathering data about reported missing persons. This will improve reporting objectives and obligations; assist the aged care industry; and support the intent of missing person legislation to improve the safety of care recipients.

Contact us for more information:

Aged Care Complaints Branch
Office of Aged Care Quality and Compliance
Email agedcomplaintscomms@health.gov.au
Website: http://agedcarecomplaints.govspace.gov.au
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