SPRINGFIELD, IL – The Illinois Department of Public Health has fined Hickory Nursing Pavilion $10,000 (Statement of Violation) for failure to provide adequate supervision to prevent residents from leaving the facility unsupervised. The 74-bed skilled and intermediate care facility is located at 9246 S. Roberts Road in Hickory Hills.

As part of an incident investigation, Department surveyors found two elderly residents, who had a history of wandering and were fitted with electronic monitors, left the facility on separate occasions undetected by staff.

One resident was found by police six blocks away without shoes. The man, who had been missing for about an hour, was taken to a local hospital for evaluation and later returned to the facility.

Two days prior to this incident, the same resident was found walking down a four-lane street in front of the facility. Despite the resident's history of wandering, the facility did not revise his care plan to address the behavior.

Another resident was found by police about one mile from the facility walking through a busy intersection and was taken to his brother's house. The brother notified staff, who had just realized the man was missing, and the resident was returned to the facility unharmed.

Department investigators found the facility did not follow its policy on electronic monitoring devices, which requires door alarms to be checked daily and resident devices to be checked each shift. Three of the facility's five exit doors were found to be not functioning properly.

A Department-ordered plan of correction required the facility to provide residents with adequate and proper supervised nursing care, to provide constant visual supervision of any exit when the alarm system is deactivated or malfunctioning, and to accurately assess residents for their risk of leaving the facility unsupervised.

Hickory Nursing Pavilion has requested a hearing on the Department's action. No hearing date has been scheduled.