Chestnut Corner Shelter Care
Facility I.D. Number: 0029108
905 W. Chestnut
Louisville, IL 62858
Date of Survey: 01/03/01
Notice of Violation: 2/08/01 - Incident Investigation
COMPLAINT INVESTIGATION #0051850 AND LICENSURE - BED LEVEL UPGRADE
Every existing facility shall have each exterior door equipped with a signal that will alert personnel in the area if a resident leaves the building. Any exterior door that is supervised during the day. . . may have a disconnect service for part-time use. If there is constant 24-hour-a-day supervision of the door, a signal is not required.
Based on incident report review, record review, observation and interviews, the facility failed to constantly supervise exit doors while the alarm was disconnected, resulting in a resident elopement on 12/23/00.
1) Per incident report review plus interviews, on 12/23/00, R1 eloped from the facility sometime between 7:30AM and 9:30AM. Per interview with E4, the facility door alarms in the East building are shut off at approximately 6AM and were off at the time R1 eloped and the doors were not under constant staff supervision.
R1 was returned to the facility at 9:30AM by E9 (location of resident was not determined and place of return could not be established). R1 left the facility again as E9 left R1, unsupervised to obtain her coffee at approximately 9:35AM. Again the door alarms were disconnected and constant supervision was not present for the doors. Local police and facility staff searched for three and one-half hours and were unable to locate R1. R1 has not been found to date. Temperature on 12/23/00 at 7:00AM was 12 degrees per WNOI radio information-Range on 12/23 14 degrees to 1 degree.
R1 is a 50-year-old resident admitted 11/02/00 with diagnoses of Chronic Schizophrenia Paranoid Type with acute exacerbations. R1 was admitted from Choate Mental Health Center as she failed to take care of herself and take her medications while living independently.
R1 was noted to have delusions of reference and poor insight/judgement according to the psychiatrist note on 12/08/00 and per interview with Z2. R1 was her own guardian and did not sign out for the leaves (according to facility policy). Per staff interview, R1 could not live independently.
2) R1 has a history of elopement per history and physical from Choate Mental Health & Development Center. R1 also attempted to leave this facility 11/23/00 and was found Hitchhiking by the sheriff's department on highway 45. Again the door alarms were off and no constant supervision present.
3) Upon entrance to the facility 01/03/00 at 8:30AM, the West entrance doors of the West Building were noted to be unsupervised and no alarms sounded when the surveyor entered. According to E1, the alarms are turned off during the day and constant supervision is not done for these doors.