# Elopement

> Elopement is when a patient or resident slips out of a facility without staff knowing, when supervision is needed. CMS cites it at F689.

Source: https://incidentkit.ai/glossary/elopement · Updated Oct 5, 2026

Also known as: unauthorized departure, patient elopement, resident elopement

## How the term is used

CMS guidance says a resident has eloped when they leave the building or a safe area without staff knowing, and supervision is needed.

A resident who can make their own choices and leaves on purpose has generally not, unless staff do not know about it or where they are.

If staff know, and the risks were explained, it is leaving against medical advice. Wandering is random or repeated movement that can come before elopement.

The Joint Commission counts an elopement (unauthorized departure) as a [sentinel event](https://incidentkit.ai/glossary/sentinel-event) if it leads to death, permanent harm or severe harm. This covers settings staffed around the clock, including the emergency department.

## What CMS expects

Facilities must find and assess residents at risk, watch them and put steps in the care plan. Alarms help but do not replace supervision, and they need scheduled upkeep and testing. The emergency plan should say how to find a missing resident.

CMS names the risks: heat or cold exposure, dehydration, other medical problems, drowning and being hit by a vehicle. Poor supervision is cited at F689.

Example: a resident with dementia and a record of exit-seeking leaves through a service door whose alarm was broken. Staff find the resident in the parking lot. That is an elopement and a likely [F689](https://incidentkit.ai/glossary/f-tag) finding.

## Frequently asked questions

### Is leaving against medical advice an elopement?

No, under CMS guidance. If a resident leaves with the facility's knowledge, after the risks were explained, it is leaving against medical advice. Record the options offered, risks explained and when staff learned.

### Is every elopement a sentinel event?

No. The Joint Commission counts it only when it leads to death, permanent harm or severe harm. Others are still safety events needing review.

### Do door alarms satisfy the requirement?

No. CMS says alarms help but do not replace supervision. Staff must respond fast, and alarms need scheduled upkeep and testing.

## Sources

- [CMS State Operations Manual, Appendix PP: Guidance to Surveyors for Long Term Care Facilities](https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf)
- [Joint Commission: Sentinel Event Policy (SE chapter), Comprehensive Accreditation Manual, Update 1, July 2026](https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/camncc_20_se_all_current.pdf)

## Related terms

- [Sentinel event](https://incidentkit.ai/glossary/sentinel-event)
- [F-tag](https://incidentkit.ai/glossary/f-tag)
- [Immediate jeopardy](https://incidentkit.ai/glossary/immediate-jeopardy)
- [Adverse event](https://incidentkit.ai/glossary/adverse-event)
- [Harm scale](https://incidentkit.ai/glossary/harm-scale)

## Related

- [F689 accidents and supervision: falls, hazards, devices](https://incidentkit.ai/compliance/f-tags/f689)
- [Incident reporting software for skilled nursing facilities](https://incidentkit.ai/solutions/skilled-nursing-facilities)
- [Incident reporting software for assisted living](https://incidentkit.ai/solutions/assisted-living)
- [Incident reporting software for behavioral health](https://incidentkit.ai/solutions/behavioral-health)
- [Joint Commission sentinel event policy: definition and RCA](https://incidentkit.ai/compliance/reporting-deadlines/sentinel-events)
- [Incident reporting in healthcare: the complete guide](https://incidentkit.ai/guides/incident-reporting-in-healthcare)