SPRINGFIELD, IL – The Illinois Department of Public Health has fined The Imperial Grove Pavilion $10,000 (Statement of Violation), for failure to properly assess a resident for risk of leaving the facility. The 248-bed skilled care facility is located at 1366 W. Fullerton Ave. in Chicago.

Responding to complaints, Department surveyors learned a wheelchair-bound resident sustained numerous injuries, including head trauma, several fractures and cuts, when she fell down a flight of stairs while attempting to leave the facility. The resident was taken to a local hospital for treatment after a nurse found her lying in a stairwell.

About a week prior to the incident, the resident had become agitated and, on several occasions, was observed trying to leave the floor via the elevator and the stairs. The resident's physician told surveyors that, five days prior to the incident, staff told him of the resident's attempts to leave the floor.

Despite this change in behavior, the facility did not reassess the resident's care plan or implement steps to more closely supervise the resident to prevent her from leaving the facility.

The Department-ordered plan of correction required the facility to provide adequate supervision of residents, to document changes in residents' conditions and to ensure staff are aware of the level of care required by each resident.

The Imperial Grove Pavilion has requested a hearing on the Department's action. No hearing date has been set.