Per interview with E1, E2 and nursing staff, the facility did not conduct a resident head count to determine if any other residents were missing. The east wing has three other residents with history of wandering on the unit. This was signed by 25 staff members. When the surveyor asked to see the policy that was discussed the facility stated that they did not have a written policy on response to door alarms. They did have an elopement policy which is to be implemented once it is recognized that a resident is missing.
Staff are to leave the alarm sounding until the doors have been checked.
The facility included a new policy to also conduct a count of residents deemed to be at risk for wandering or elopement if the alarm was unwitnessed. Staff's failure to adequately supervise R1 and failure to respond appropriately to the door alarm system allowed R1 to leave the facility in a merry walker without staff's knowledge and subsequently receive an injury to the head, shoulder and wrist.