June 7, 2001

SPRINGFIELD, IL – The Illinois Department of Public Health has fined Manor at Lincolnwood Place $10,000 (Statement of Violation) for failure to adequately supervise a resident with a history of wandering. The 65-bed skilled and sheltered care facility is located at 7000 N. McCormick Blvd. in Lincolnwood.

Responding to an incident report, Department investigators learned a resident left the facility unnoticed about 2 a.m. and was found the next morning face down in the snow between two vehicles in an automobile dealership parking lot which is about 1,000 feet from the facility. The woman was transported to a local hospital emergency department where she was pronounced dead from hypothermia.

The resident, who had been missing for about six hours, was dressed only in a housecoat and was not wearing shoes. The overnight temperature was between 8 degrees and 10 degrees.

Per staff interviews, surveyors found the resident had been wandering around the facility much of the previous evening and had to be redirected to her room several times. While conducting rounds, a nurse -- who had previously guided the resident back to her room -- noticed the resident was not in her room and a search of the facility failed to locate her.

It is assumed the resident left through an east exit door that is also used as an entrance for the facility's assisted living section. This door requires a key card to enter the facility, but there is no alarm on the door or key card required for exit.

A Department-ordered plan of correction required the facility to ensure that supervision precautions are in place for residents diagnosed with wandering behaviors and that all resident-accessible exterior doors are equipped with an alarm or are visually monitored.

Manor at Lincolnwood Place has requested a hearing on the Department's action. No hearing date has been set.