November 2, 2001

SPRINGFIELD, IL – The Illinois Department of Public Health has fined the Illinois Veterans Home at Manteno $5,000 (Statement of Violation) for failure to provide adequate supervision to prevent residents from leaving the facility unsupervised. The 340-bed skilled facility is located at 1 Veterans Drive in Manteno.

As part of an incident investigation, Department surveyors found an elderly resident, who had a history of wandering, left the facility undetected by staff, climbed over a 5-foot, chain-link fence and got off the facility's grounds. A wheelchair-bound resident also left the facility unnoticed and was found two blocks away but still inside the home's fence.

An employee of a local bank alerted the facility and helped the resident who climbed the fence get down after his foot got stuck.

Staff did not know how the two residents, who were both identified at risk for their safety, had left their units and reached the fence undetected.

Following the incident, a physician stated that the resident who climbed the fence needed to be in a closed unit or needed to be supervised closely in an open unit. During the investigation, a surveyor observed the resident leave the unit unsupervised to play pool in another wing. The walk to the recreation room pool table included nine exits, several turns and two interconnecting tunnels.

The resident's records indicated that he has short- and long-term memory impairment and wandering problems. Despite the resident's history of wandering, the facility did not revise his care plan to address the behavior.

The Department-ordered plan of correction required the home to provide residents with adequate and proper supervised nursing care; to review, and revise as necessary, its policies and procedures regarding elopements; and to perform comprehensive assessments of residents with a history of or potential for wandering.

Illinois Veterans Home has requested a hearing on the Department's action. No hearing date has been set.