May 8, 2000

CAHOKIA NURSING HOME FINED FOR POOR SUPERVISION

SPRINGFIELD, IL -- River Bluffs Nursing and Rehabilitation Center has been fined $10,000 (Statement of Violations) by the Illinois Department of Public Health for failure to properly supervise residents, investigate reports of serious incidents and report these occurrences to the state. The 130-bed skilled and intermediate care facility is located at 3354 Jerome Lane in Cahokia.

Responding to a complaint and as part of an annual license survey, Department staff learned of several incidents that the administration denied knowledge of, including one in which a resident wandered from the facility and was found about 17 miles away lying mud-covered along the side of a highway.

Surveyors were able to verify that incident, which came to the Department’s attention through an anonymous complaint and through interviews with the Cahokia Police Department and a hospital that cared for the 52-year-old woman. She was treated for hypothermia and returned to the facility. The police had been called by the facility to report the resident missing 2 ½ hours before she was found.

The facility failed to notify the Department within 24 hours of this incident, which took place in April 1999, and others as required by state law.

In another case, surveyors were told by current and former staff of a 64-year-old resident who had twice left the facility without staff knowledge. Once the resident was found walking about two miles from the facility and another time he was located walking along Interstate 255. Both times staff were able to return the man unharmed. There was nothing in the resident’s file that documented the incidents or noted that the Department had been notified.

A third resident with a history of wandering was twice able to leave the facility unnoticed by staff. The resident was discovered once lying under the bushes outside the facility and, on a second occasion, was found 50 yards from the rear of the building in the ice and snow. A partial investigation by the director of nursing the first time the resident left the facility concluded that the door alarms were not answered in a timely manner. The nurse in charge at the time of this incident said no door alarms sounded.

River Bluffs Nursing and Rehabilitation Center has requested a hearing on the Department’s action. A hearing date has not been scheduled.

Illinois Department of Public Health 535 West Jefferson Street Springfield, Illinois 62761 Phone 217-782-4977 Fax 217-782-3987 TTY 800-547-0466 Questions or Comments