February 23, 2000

SPRINGFIELD, IL – Pittsfield Manor has been fined $10,000 (Statement of Violation, Final Order) by the Illinois Department of Public Health for failure to properly supervise a resident who wandered unnoticed from the facility, sustained injuries in a fall and later died at a local hospital. The 81-bed skilled care facility is located at 610 Lowry St. in Pittsfield.

Responding to an incident report filed by the facility, Department surveyors learned a 78-year-old resident left the facility without staff's knowledge at approximately 1:30 p.m. on Sept. 26, 1999. She was observed about a quarter of a mile away along Jill Street by a citizen, who called for an ambulance. The resident was transported to a local hospital where she was treated for facial trauma and bleeding. She died at 4:15 p.m.

The facility was not aware the woman was missing until the Pike County Sheriff's Office contacted staff about an elderly woman who had been injured. Deputies had a first name for the woman and, upon checking, facility staff discovered she was missing.

No one could explain how the woman, who had been identified as a high risk for elopement and falls, was able to leave the facility. A check of facility door alarms found all were functioning properly. In the 12 days before she was able to wander away, the resident had attempted to leave the facility eight times.

The Department and Pittsfield Manor reached a consent agreement Jan. 24, 2000, on the disciplinary action. As part of the agreement, the facility withdrew a hearing request and agreed to follow a Department-imposed plan of correction. The Department reduced the facility's fine to $5,000.

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