A Resident Who Wants to Leave Against Advice
You are a CNA in a skilled nursing facility. Mr. Brennan, age 81, has mild cognitive impairment and uses a walker. He is alert and oriented to person, place, time, and situation. At 19:30 he puts on his coat and says he is walking home, about a mile away, in the dark and cold. His care plan does not restrict him, and he has no physician order limiting his movement. There is no wandering alert on his door. The charge nurse is at dinner. The front door has an alarm that sounds when opened, and the receptionist has already gone home.
1. What is the safest sequence of actions, and how do you reason about restraint versus autonomy?
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He has the right to leave unless a valid order and legal process say otherwise. Your job is to make the departure as safe as possible while getting help.
- Do not physically block or restrain him. Physically stopping a resident who has not been adjudicated incompetent can be false imprisonment, and a struggle with an 81-year-old walker user risks a fall.
- Engage him and buy time. "It's dark and cold - let me get you a coat and call someone to walk with you." Offer a warm drink, a call to family, or a ride. Delay with conversation, not force.
- Get the charge nurse now. Call or page rather than waiting for dinner to end. The nurse must assess capacity and decide the next step.
- Notify the supervisor on duty and follow facility policy for a resident leaving the premises, including who calls family and whether law enforcement is notified.
- Document the time, his exact statements, what you offered, and who you notified.
- Reasoning: autonomy is the default for a resident who is oriented and not under a restricting order. Safety planning and notification replace restraint. If his cognition were such that he could not appreciate the risk, the nurse's capacity assessment would drive the response, not the CNA's judgment alone.
2. He leaves. What do you do in the first 30 minutes, and what would have been the warning signs that this needed a care plan change earlier?
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First 30 minutes:
- Note the exact time and direction he left, what he was wearing, and whether he took his walker.
- Tell the charge nurse and supervisor immediately - do not search alone and do not leave the unit uncovered.
- Follow the facility's missing-person policy: who calls family, who calls law enforcement, and who documents. Do not improvise around the policy.
- Document factually in the record and in any incident report.
Earlier warning signs that should have triggered a care plan review:
- Any prior talk about going home, packing, or asking about the door.
- Mild cognitive impairment plus a walker plus nighttime restlessness.
- A door alarm with no staffed reception in the evening - the alarm only helps if someone responds.
- No documented discussion of his exit-seeking behavior at care conferences.
The lesson is that the CNA is often the first to see a pattern. Reporting "he keeps talking about walking home" at the time is what allows the team to plan before the door opens.