Nursing Home Elopement and Wandering Litigation: What Attorneys Need From Medical Experts

Most claims in elder care litigation build slowly: a wound that worsens over weeks, an infection that goes unrecognized for days. Elopement is different. A resident with dementia leaves a secured unit or a facility without staff knowing, and the outcome is often decided within hours by weather, water, traffic, and terrain. There is no MDL and no bellwether calendar for these claims. They are tried one resident at a time in state court, against nursing homes, assisted living and memory care operators, and increasingly the companies that own and manage them. And they turn on questions no lay witness can answer: was the risk known, was it assessed and care planned, did the supervision and the building match the plan, and how fast did staff realize the resident was gone. That is why both sides need long term care nursing, dementia care, geriatric medicine and psychiatry, facility safety, and, in death cases, forensic pathology.

The Litigation Landscape

The population at risk is large and growing. The Alzheimer’s Association estimates that 7.4 million Americans age 65 and older are living with Alzheimer’s dementia in 2026.¹ The Association also reports that six in ten people living with dementia will wander at least once, and that many do so repeatedly.² Not every wandering resident elopes, and not every elopement causes harm, but the residents who do get out are the least able to recognize danger or ask for help.

Federal inspection data show how often supervision failures reach the level of a citation. Elopement is cited under F689, the federal tag for accident hazards and supervision under 42 C.F.R. Section 483.25(d), which requires that each resident receive adequate supervision and assistance devices to prevent accidents.³ In the CMS health deficiency file with a processing date of August 1, 2026, which covers the three most recent inspection cycles for every certified nursing home, F689 was cited 21,413 times out of 419,479 health citations, second only to infection control. More telling is where those citations sit on the severity grid. F689 accounts for 4,327 of the 13,434 citations at the actual harm level (scope and severity G, H, or I), about 32 percent, and 2,677 of the 9,480 immediate jeopardy citations (J, K, or L), about 28 percent. More than half of the F689 citations, 11,903, came out of complaint investigations rather than routine surveys.⁴ F689 also covers falls and other accidents, and the CMS file does not separate elopement from those, so these figures describe the supervision tag as a whole rather than elopement alone. The CMS files we checked on October 5, 2026 still carried the August 1 processing date.

Staffing is the backdrop in nearly every elopement case, because supervision is a staffing question. The federal minimum nurse staffing standards and the 24 hour registered nurse requirement became inoperative on February 2, 2026, so there is no federal numeric floor to measure against. The August 1, 2026 CMS national averages show 3.86 total nurse staffing hours per resident day, 0.69 registered nurse hours, a weekend drop to 3.42 total and 0.48 registered nurse hours, and 45.8 percent total nursing staff turnover.⁵ Many elopements happen at night, on weekends, at shift change, or while staff are busy with another resident, which is why payroll based journal data now shows up in these cases as routinely as the care plan.

CMS has also sharpened its survey focus. The LTC survey resources updated effective February 3, 2026 revised the unsafe wandering and elopement initial pool, as reported by the compliance press, to flag residents leaving secured areas without staff redirection, attempts to leave with an alarm not working, and elopement in the prior 120 days.⁶ CMS memo QSO-26-03-NH, originally released January 30, 2026 and revised April 3, 2026, updated Chapters 5 and 7 of the State Operations Manual, including expanded examples of complaints that warrant immediate jeopardy priority.⁷

Recent outcomes show what is at stake, and how far up the corporate chain these claims now reach.

• Hernandez (Sacramento County, California). On March 3, 2026, a jury returned a $110 million verdict in a case arising from the February 12, 2019 death of Mildred Hernandez, a 100 year old assisted living and memory care resident with Alzheimer’s dementia. Plaintiffs alleged that she was a known night wanderer, that her wandering was never written into her assessments or care plan, and that she went out an exit door that locked behind her, fell in the courtyard, and died of hypothermia in 38 degree weather. According to plaintiffs’ counsel, the award was $7.5 million for pre-death pain and suffering, $2.7 million in wrongful death damages, and $100 million in punitive damages against the real estate investment trust and private equity firm that owned and oversaw the facility, after the jury found malice, oppression, or fraud. The defense argued at trial that the evidence did not prove negligence caused the death. This is a jury finding specific to that case, and we found no report of a ruling on post-trial motions or an appeal.^8,9 The case is a reminder that corporate oversight, not just bedside care, is now a liability theory, and that an assisted living memory care unit is judged under state licensing law rather than F689.
• Tribble (Beaufort County, South Carolina). Plaintiffs alleged that Jack Tribble, a 79 year old man with Lewy body dementia admitted to a secured memory care unit specifically for wandering and exit seeking, followed a contractor’s employee through a keypad controlled exit on August 23, 2022, and was found dead in a swampy area two weeks later. The complaint named the facility, its corporate parents, and the contractor. The case was reported as set for trial in April 2026 and then reported settled in early May 2026; we found no public terms.¹⁰ Vendor and visitor door control is a recurring fact pattern and a source of apportionment fights.
• Petitti (Eugene, Oregon). On July 15, 2026, the Oregon Department of Human Services barred a Eugene skilled nursing facility from admitting new residents after a resident with dementia left in a power wheelchair on July 5 and was found dead on July 8, a short distance away. The state’s order alleges the resident had gotten out unnoticed on July 3 and had another incident on July 4, and that the facility did not reassess her elopement risk after either event. The order cites F744, the dementia care requirement. The facility had the right to request a hearing.¹¹
• Springfield Nursing and Independent Living, DAB CR6760 (August 25, 2025). A federal administrative law judge sustained an immediate jeopardy F689 citation and $85,420 in civil money penalties after a wheelchair dependent resident assessed as high risk for elopement was left unattended, went out an unsecured and unmonitored door, fell down concrete steps, and later died.¹² An earlier decision, Fort Worth Transitional Care Center, DAB CR6211 (2023), involved a newly admitted resident known to be an elopement risk whose exit alarms went unanswered; he was gone more than 15 hours.¹³ These administrative records, with their survey findings and timelines, are often the best evidence in the civil case.

The Injuries at Issue

Elopement injuries are mostly environmental and traumatic: hypothermia and cold exposure, heat illness and dehydration, drowning, falls from curbs, stairs, and embankments, hip and other fractures, pedestrian and traffic injuries, and wheelchair and power chair accidents. When a resident is found alive, the course afterward often includes rhabdomyolysis, pneumonia, pressure injury from hours on the ground, and a step down in cognition and function that changes the resident’s level of care. When the resident is not found quickly, the case is usually a wrongful death case, and the medical questions become time and cause of death. Hernandez died of hypothermia; the Tribble death was attributed to acute bronchopneumonia associated with environmental exposure. Psychological harm is also pleaded, including terror and conscious suffering before death, which matters for survival damages.

The Science Behind the Claims

Wandering is common, and its severity tracks the dementia. In a Dutch analysis of Minimum Data Set records from eight nursing homes, wandering that staff could not easily redirect was present in 11.2 percent of all residents and 26.6 percent of ambulatory residents, and it rose with severity of cognitive impairment. It was also more common in facilities where residents spent less time in meaningful activity.¹⁴ In U.S. nursing homes, the MDS asks about wandering directly in Section E, including whether it places the resident at significant risk of getting to a dangerous place, so the facility’s own assessment data usually establishes notice.

Elopement follows recognizable warning signs. Myra Aud’s study of 62 elopements of residents with dementia from long term care facilities found three recurring patterns: no effective precautions after a resident had expressed intent to leave, had repeatedly tried, or had a history of elopement; staff who did not know where the resident was; and alarm devices that were not used effectively.¹⁵ Risk management literature has long reported that a large share of elopements occur within the first 48 hours after admission, when the resident is disoriented and the staff does not yet know them, although that figure comes from industry sources rather than peer reviewed data and should be presented that way.¹⁶ Exit seeking statements, shadowing staff to doors, and attempts to remove a monitoring bracelet are the soft signs nursing experts look for in the chart.

Time to find is the outcome variable. In Koester and Stooksbury’s review of Virginia search and rescue incidents involving people with probable Alzheimer’s disease, overall mortality was 19 percent, there were no deaths among those found within 24 hours, and mortality was 46 percent among those who took longer to locate. Most were found within about a mile of where they were last seen.¹⁷ Rowe and Bennett’s review of 93 people with dementia found dead after becoming lost found that 87 percent were found in natural, secluded areas such as woods, fields, ditches, and water, usually less than a mile away but often after long delays.¹⁸ In a later study of 325 missing person cases, Rowe and colleagues found that 90 percent of those found alive were located within two days, compared with 50 percent of those found dead. Those found dead were closer to where they were last seen but took longer to find.¹⁹ All three studies rely on search records or press reports and overrepresent deaths, a point the defense will make, but the direction is consistent: minutes and hours matter, and so does when staff notice the absence and call for help.

Prevention evidence is thinner than many policies suggest. A Cochrane review found no randomized or controlled trials supporting subjective exit barriers such as floor grids, mirrors, or camouflaged doors, and found the available studies unsatisfactory.²⁰ That cuts both ways. Plaintiffs will argue that because cosmetic barriers are unproven, the facility needed supervision and working alarms. Defendants will argue that no intervention eliminates elopement and that the standard is reasonable care, not a guarantee.

The restraint problem. Federal rules require facilities to keep residents free of physical and chemical restraints not required to treat medical symptoms (F604, F605), and CMS guidance recognizes that position change alarms can themselves function as restraints if they cause a resident to stop moving.²¹ Facilities cannot simply lock residents in a room or sedate them, and the defense will frame its choices as a balance between safety and the resident’s rights. A good expert explains where that balance actually lay for this resident: a secured unit, an individualized supervision level, activity programming, and a reassessment after every attempt.

Why Expert Witnesses Are Critical, by Specialty

Long term care nursing and directors of nursing. The core liability witness. This expert reconstructs the risk picture from admission paperwork, the MDS Section E coding, elopement risk assessments, nursing notes, behavior monitoring flowsheets, and incident reports of prior attempts, then compares it with the care plan required by F656 and the supervision actually delivered. They also reconstruct the critical hours: last documented check, when the absence was noticed, when a building and grounds search began, and when police and family were called.

Nursing administration and staffing. With the federal floor gone, staffing arguments rest on the facility assessment, acuity, and payroll based journal records for the specific shift. This expert addresses whether the staffing on that shift could have delivered the supervision level in the care plan, and, in cases like Hernandez, how corporate budgets, management agreements, and operator turnover shaped what happened on the floor.

Dementia care and memory care specialists. Certified dementia practitioners and memory care administrators address F744 and its state law equivalents: person centered behavior plans, activity programming, triggers such as sundowning or unmet needs, and whether the unit was designed and run as a true secured unit. In assisted living cases, they translate the state licensing rules and the facility’s own marketing promises into a standard of care.

Geriatric medicine and geriatric psychiatry. These physicians address whether a change in exit seeking reflected delirium, infection, pain, or medication effects that should have prompted a medical evaluation, and whether psychotropic use was appropriate under F758. They also give the causation testimony many states require from a physician, connecting a supervision failure to the injury or death to a reasonable degree of medical certainty.

Facility safety and building systems. Door hardware, delayed egress locks, keypad codes, wander management systems, alarm logs, and camera footage are often decisive. An expert in health care life safety and security can test whether the system worked, whether staff disabled or ignored alarms, and how vendors and visitors were managed, which matters for apportionment when a contractor or visitor held the door.

Emergency medicine, trauma, and critical care. For residents found alive, these experts address the injuries on arrival, core temperature, rhabdomyolysis, fracture care, and whether the elopement caused the decline that followed. They are also needed when the defense argues that hospital care, not the elopement, drove the outcome.

Forensic pathology. In death cases, a forensic pathologist addresses cause and time of death, the findings in hypothermia and drowning, the significance of injuries from falls, and whether underlying disease contributed. Time of death findings can anchor the conscious suffering claim and test the facility’s account of when the resident left.

Life care planning and forensic economics. For survivors whose level of care permanently changes, these experts quantify the future care costs.

What Attorneys Should Look For

For nursing experts, look for real long term care or memory care floor and DON experience, not only hospital experience, and familiarity with MDS coding and the F689, F656, and F744 survey guidance. For dementia care experts, credentials such as CDP and hands on experience running a secured unit. For physicians, active practice with nursing home patients and the discipline to separate the risk the chart shows from the risk the expert infers. For facility safety experts, experience with health care occupancies rather than general commercial security. For every expert, a clean testimony history, and a report that builds the timeline from the records first and draws conclusions second. Survey reports and plans of correction are public and are usually the fastest way to test an expert’s theory before retention.

Key Dates

Date	Event
1995	Koester and Stooksbury report no deaths among lost Alzheimer’s patients found within 24 hours, 46 percent mortality after
November 2004	Aud publishes analysis of 62 elopements from long term care facilities
June 2011	Rowe and colleagues publish study of 325 missing person cases involving people with dementia
August 23, 2022	Jack Tribble leaves a South Carolina memory care unit behind a contractor’s employee
August 8, 2024	CMS revision 225 to F689 guidance in Appendix PP
April 28, 2025	Revised long term care surveyor guidance takes effect, including the F604 restraint guidance that addresses position change alarms
August 25, 2025	DAB CR6760 sustains an immediate jeopardy F689 citation and $85,420 in penalties after a fatal elopement
January 30, 2026	CMS releases QSO-26-03-NH revising State Operations Manual Chapters 5 and 7 (revised April 3, 2026)
February 2, 2026	Federal minimum nurse staffing standards and the 24 hour RN requirement become inoperative
February 3, 2026	Updated LTC survey resources take effect, including the revised unsafe wandering and elopement initial pool
March 3, 2026	$110 million Sacramento County jury verdict in the Hernandez assisted living elopement case
May 2026	Tribble wrongful death case reported settled
July 15, 2026	Oregon bars new admissions at a Eugene facility after a fatal July 5 elopement
August 1, 2026	CMS Care Compare data: F689 cited 21,413 times, about 28 percent of all immediate jeopardy citations

How Med Legal Pro Helps

Elopement cases are won or lost on two timelines: how long the facility knew the resident was at risk, and how long the resident was gone before anyone noticed. Med Legal Pro places long term care nurses and directors of nursing, nursing administrators, dementia care specialists, geriatric medicine and geriatric psychiatry physicians, emergency and critical care physicians, forensic pathologists, and life care planners on plaintiff and defense matters. Learn more about our nursing home expert witness services, and see our related guides on pressure injury and sepsis and infection litigation. We run a conflict check before any expert speaks with counsel, and every report goes through internal review before it reaches you. The Expert for Experts.

Sources

1. Alzheimer’s Association. 2026 Alzheimer’s Disease Facts and Figures. alz.org
2. Alzheimer’s Association. Wandering. alz.org
3. 42 C.F.R. Section 483.25(d), accidents (F689); Section 483.40(b)(3), dementia treatment and services (F744); Section 483.21(b), comprehensive care plans (F656). ecfr.gov
4. CMS Provider Data Catalog, Nursing Home Health Deficiencies, processing date August 1, 2026 (tabulated by tag, scope and severity code, and complaint flag). data.cms.gov
5. CMS Provider Data Catalog, Nursing Home State and US Averages, processing date August 1, 2026. data.cms.gov
6. CMS Compliance Group. CMS Updated LTCSP Survey Resources Folder, February 13, 2026 (survey resources effective February 3, 2026). cmscompliancegroup.com
7. CMS, QSO-26-03-NH, Revisions to the State Operations Manual Chapters 5 and 7, released January 30, 2026, revised April 3, 2026. cms.gov
8. Dudensing Law. The Hernandez Verdict (Sacramento Super. Ct., Judge Jeffrey Galvin, verdict March 3, 2026). dudensinglaw.com
9. Law&Crime. Coverage of the Hernandez complaint and trial, including defense positions, January 22, 2026. lawandcrime.com
10. Tribble v. National Healthcare Corp., et al., Summons and Complaint (S.C. Ct. Com. Pl.) rplegalgroup.com; The Island Packet, settlement reported May 5, 2026 wn.com
11. Oregon Department of Human Services, Notice and Order Imposing License Condition, Case No. NFCD26-00059 (July 15, 2026) lookouteugene-springfield.com; KLCC, July 16, 2026 klcc.org
12. Springfield Nursing & Independent Living, DAB CR6760 (HHS Departmental Appeals Board, ALJ, August 25, 2025). hhs.gov
13. Fort Worth Transitional Care Center, DAB CR6211 (HHS Departmental Appeals Board, ALJ, 2023). hhs.gov
14. Volicer L, van der Steen JT, Frijters DH. Involvement in activities and wandering in nursing home residents with cognitive impairment. Alzheimer Disease and Associated Disorders. 2013;27(3):272-277. doi:10.1097/WAD.0b013e31826d012e
15. Aud MA. Dangerous wandering: Elopements of older adults with dementia from long-term care facilities. American Journal of Alzheimer’s Disease and Other Dementias. 2004;19(6):361-368. doi:10.1177/153331750401900602
16. Struck K. Elopement: Assessment and Safety Essentials. Provider, May 2013 (citing Briggs Corp. data). providermagazine.com
17. Koester RJ, Stooksbury DE. Behavioral profile of possible Alzheimer’s disease patients in Virginia search and rescue incidents. Wilderness and Environmental Medicine. 1995;6:34-43. dbs-sar.com
18. Rowe MA, Bennett V. A look at deaths occurring in persons with dementia lost in the community. American Journal of Alzheimer’s Disease and Other Dementias. 2003;18(6):343-348. doi:10.1177/153331750301800612
19. Rowe MA, Vandeveer SS, Greenblum CA, et al. Persons with dementia missing in the community: Is it wandering or something unique? BMC Geriatrics. 2011;11:28. doi:10.1186/1471-2318-11-28
20. Price JD, Hermans DG, Grimley Evans J. Subjective barriers to prevent wandering of cognitively impaired people. Cochrane Database of Systematic Reviews. 2001, CD001932. doi:10.1002/14651858.CD001932
21. CMS, State Operations Manual Appendix PP, F604 (Rev. 229, issued April 25, 2025, implementation April 28, 2025), including the definition of position change alarms. cms.gov

Tracy L. Liberatore Esq, PA-Emeritus, Med Legal Pro. This article is general information for attorneys and is not legal or medical advice. All claims described in pending or recently tried cases are allegations unless and until finally adjudicated.