SPRINGFIELD, IL – Maplewood Care has been fined $10,000 (Statement of Violation by the Illinois Department of Public Health for failure to safely store controlled substances, to maintain a living environment free of hazards and to immediately investigate a drug theft. The 203-bed skilled care facility is located at 50 N. Jane in Elgin.

Responding to a complaint, Department surveyors learned a female resident took morphine from a nurse's cart and gave it to a male resident, who later died from an overdose of the drug. Another resident had observed the theft and reported it to a nurse, but she did not investigate the incident or share the information with a co-worker.

When the nurse realized 14 tablets of morphine were missing from her cart, she called her supervisor, who told her to write a note and slip it under her office door and she would follow up on it in the morning. The supervisor also told the nurse there was no need to monitor the resident because she would not overdose.

Nearly seven hours later, the male resident given the morphine was banging his head on a dresser and was transported to the emergency room and admitted for a drug overdose.

The resident had a history of substance abuse and was admitted to the facility after attempting to overdose on heroin. His pre-admission screening stated he was in need of structure and supervision.

Following the incident, the female resident signed herself out of the facility against medical advice. She later confessed to stealing morphine and giving it to the male resident so he could get high. She has been charged with drug induced homicide, delivery of a controlled substance and possession of a controlled substance.

Surveyors found the female resident's care plan did not address an arrest for shoplifting and her suicidal statements and did not evaluate her medication seeking behaviors.

The Department-ordered plan of correction required the facility to review its policies regarding administering medications and reporting of medication errors; to ensure medications are locked in a medication cabinet, room or cart; to take disciplinary action against any staff failing to report, monitor or take appropriate action in relation to medication issues; and to have adequate staff to meet residents' needs.

Maplewood Care requested a hearing on the Department's action. No hearing date has been scheduled.