SPRINGFIELD, IL – The Illinois Department of Public Health has fined Harrisburg Care Center $5,000 (Statement of Violation) for failure to take the necessary precautions to prevent a resident from leaving the facility unsupervised. The 68-bed skilled care facility is located at 1000 W. Sloan St. in Harrisburg.

As part of an incident investigation, Department surveyors learned a resident, who had a history of wandering and attempting to exit the facility, left the center unnoticed. A member of the community observed the resident sitting on the ground in a cemetery about a quarter of a mile away from the facility and notified the police. The facility was unaware the resident was missing until they were contacted by the police. The woman was returned to the center unharmed.

When the resident exited the facility and briefly activated a door alarm, staff members told surveyors they assumed visitors were leaving the facility and did not check the door. At the time, the alarm code was posted outside the door but could be read from inside the facility.

A review of the resident's care plan revealed she was to be monitored and redirected from exits. The facility, however, did not have a policy for how to monitor residents considered at risk for wandering.

A Department-ordered plan of correction required the facility to maintain all exterior door alarms, to ensure constant visual supervision for all resident-accessible exterior doors not equipped with alarms and to ensure staff respond to a signal that has been activated. Facility administration will also review policies and procedures to ensure residents with wandering behaviors are provided with the level of care and supervision necessary to meet their needs.

Harrisburg Care Center did not request a hearing on the Department's action.