|May 9, 2001
CARBONDALE NURSING HOME
SPRINGFIELD, IL The Illinois Department of Public Health has fined The Abbey of Carbondale $10,000 (statement of violation) for neglecting to ensure a resident was provided the necessary supervision to avoid physical harm. The 239-bed skilled care facility and facility for developmentally disabled persons under the age of 22 is located at 120 N. Tower Road, Carbondale.
Responding to an incident report, Department surveyors learned a 6-year-old, who suffered from a disorder that in its later stages caused the child to fall frequently, fell twice and died less than 48 hours after being admitted to The Abbey.
About 12 hours after moving to the facility from a local hospital, the boy was found in his room with a head laceration that required five stitches. Just 22 hours later the boy again fell in his room, could not be revived and was pronounced dead at a local hospital. A coroner's report concluded the boy "died from bleeding inside his head caused by a severe blow to his head, consistent with a fall onto a hard floor."
A review of The Abbey records found staff did not complete a comprehensive pre-admission assessment of the child to ensure his needs could be met as required by the facility's policies and procedures, did not provide sufficient monitoring and supervision to prevent injury and did not take correct action to prevent further injury after the child fell the first time.
The child, who had previously been cared for at home by his mother, needed constant monitoring because he would crawl out of his crib or bed. When the boy was returned after being treated at the hospital for the injury sustained in the first fall at The Abbey, the door to his room was closed and he was left unsupervised.
A Department-ordered plan of correction required the facility to ensure only persons who have had a comprehensive evaluation of their medical history, and physical and psychological factors be admitted. In addition, the facility was ordered to make sure a sufficient number of qualified staff be on duty to provide services that meet the total needs of the residents.
The Abbey has requested a hearing on the Department's action. No hearing date has been set.
of Public Health
535 West Jefferson Street
Springfield, Illinois 62761
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