| Updated August 7, 2007 from January 3, 2002
DECATUR FACILITY FINED FOR INADEQUATE SUPERVISION
SPRINGFIELD, IL – Lincoln Manor has been fined $10,000 (Statement of Violation) by the Illinois Department of Public Health for failure to prevent a resident from leaving the facility unsupervised. The 140–bed skilled and intermediate care facility is located at 2650 N. Monroe St. in Decatur.
Responding to an incident report, Department investigators learned a resident, who had a history of wandering, sustained a fractured hip and contusions to her right cheek in a fall after leaving the facility unnoticed. A passerby found the resident lying at the end of the facility's driveway and alerted staff.
The resident had been fitted with an electronic monitor about six months before after she left the facility and was found uninjured. The monitor was in place the night of the most recent elopement and it sounded when the women was brought back into the facility and later when she was transferred to a local hospital for treatment. Staff, however, could not remember hearing the alarm earlier in the evening when the resident slipped out.
During the Department's investigation, surveyors learned some family members and other visitors have the code to silence the alarm system in the building.
A Department-ordered plan of correction required the facility to review its policies and procedures regarding residents identified at risk for wandering, to conduct comprehensive assessments of residents with wandering behaviors, and to develop and implement interventions to prevent residents from wandering.
Lincoln Manor requested a hearing on the Department's action. The violation was affirmed through the administrative hearing process, but was overturned by the courts on May 21, 2004 and July 14, 2005.
of Public Health
535 West Jefferson Street
Springfield, Illinois 62761
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