December 29, 2000

SPRINGFIELD, IL – The Illinois Department of Public Health has fined Pediatric Rehab Institute $10,000 (Statement of Violation) for failure to take the necessary precautions to prevent a resident's death. The 150-bed skilled care facility for persons under 22 years of age is located at 7464 N. Sheridan Road in Chicago.

Responding to an incident report and complaints, surveyors discovered a 2-year-old resident died after his breathing tube somehow became dislodged. The child, who had a history of removing his tracheostomy, was to be monitored every two hours but, on the night of his death, had not been checked for more than 3 ½ hours. On rounds that evening, facility staff reported they had observed the child from the doorway, apparently sleeping with a blanket over his head, but they did not enter the room and check him.

During early morning rounds, a staffer found the child's tracheostomy tube had come out and he was not breathing. Staff were unable to revive the boy.

A review of the resident's file found the facility had not taken steps to address his behavior of removing the tracheostomy tube nor did staff consult with his physician to determine what precautions should be taken.

Surveyors also found inconsistencies in what guidelines were in place for monitoring residents with tracheostomies. In three other instances, the facility failed to provide corrective action for residents who pulled their tracheostomy tubes out.

A Department-ordered plan of correction required facility administration to ensure resident care plans are re-evaluated as necessary to meet the personal safety and health needs of its residents.

Pediatric Rehab Institute has requested a hearing on the Department's action. A hearing date has not been scheduled.