SPRINGFIELD, IL – The Illinois Department of Public Health has fined Carrington Care Center $5,000 (Statement of Violation) for failure to properly supervise residents to prevent them from leaving the facility. The 206-bed skilled care facility is located at 759 Kane St. in South Elgin.

As part of an incident investigation, Department surveyors learned two residents had left the facility unsupervised.

A wheelchair-bound resident sustained injuries on two occasions after wandering from the facility without the staff's knowledge. The first time, she was treated at a hospital for a laceration to her head after falling out of her wheelchair; the second incident resulted in a bump on her head and an abrasion to her knee.

A review of the resident's records revealed she was at risk of wandering, but was not identified as an elopement risk.

Another resident left the facility unnoticed and was observed sitting on a curb about two blocks away by a member of the community. Paramedics were called, but the resident was unharmed.

Although the resident repeatedly told staff he wanted to go home, he was not assessed for risk of leaving until after the incident.

Staff were unable to say how the residents were able to leave the facility unnoticed, but during a visit to the center, Department surveyors noted alarms on two of the facility's outside exits did not sound when the doors were opened.

A Department-ordered plan of correction required the facility to review its policies and procedures regarding residents at risk for wandering, to accurately assess residents for their risk of leaving the facility unsupervised, and to develop and implement interventions to prevent residents from wandering. In addition, the facility was ordered to maintain all door alarm systems.

Carrington Care Center has requested a hearing on the Department's action. No hearing date has been set.