SPRINGFIELD, IL – The Illinois Department of Public Health has fined Greenwood Terrace Nursing and Rehabilitation Center $10,000 (Statement of Violation) and (Statement of Violation) for failure to prevent residents from leaving the facility unsupervised on two separate occasions. The 237-bed skilled and intermediate care facility is located at 225 Castellano Drive in Swansea.

Department surveyors determined that two residents, both of whom had histories of wandering and were fitted with electronic monitors, were able to leave the facility unnoticed. One resident was found a block away by a visitor and returned to the facility unharmed and the other, who also was uninjured, wandered across the street and was discovered by a neighbor.

In the case of the first resident, he was observed a few hours prior to leaving the facility in a different hall than the one in which he resided. He was returned to his room and staff were to check on him every 15 to 20 minutes. A review of facility records found no documentation that the checks were performed.

Although the resident had made several attempts to leave the facility, he was not identified by staff as a threat to wander.

In addition, surveyors learned staff did not follow proper procedure for responding to a door alarm after the resident left the facility. Two staff members looked out the front door after the alarm sounded but did not check outside and a head count was not taken to determine if a resident was missing.

The second resident apparently left the facility through a door that had been left ajar and the alarm turned off. Staff speculated another resident may have shut off the alarm when going outside to smoke.

Department-ordered plans of correction required the center to properly supervise residents, to train staff on how to assess resident risk of elopement, and to identify and monitor high-risk residents.

Greenwood Terrace has requested a hearing on the Department's action. No hearing date has been scheduled.