SPRINGFIELD, IL – Raintree Terrace has been fined $50,000 (Statement of Violation), by the Illinois Department of Public Health for failure to provide proper nursing care and adequate supervision to prevent a resident death. The 16-bed intermediate care facility for the developmentally disabled is located at 501 E. Chestnut in Carbondale.

As part of an incident report investigation, Department surveyors learned a resident, who was to be monitored while bathing, was found in the bathtub with her face submerged in approximately 5 inches of water. The resident was removed from the tub and cardiopulmonary resuscitation was started while 911 was called. The resident was transferred to the local emergency department, where she died of complications due to drowning.

A review of the resident's records revealed that she had a history of seizures and was to wear a helmet during waking hours, except when being given a bath. Staff were to supervise her when she was not wearing a helmet.

An employee said he removed the resident's helmet and then left her alone in the bathroom with the water running while he went to assist another resident who was taking a bath. While dressing the second resident, the employee said he was still able to see the first resident in the bathroom. After he finished dressing the other resident, the employee, who was the only staff member available to assist with residents' personal care needs at the time of the incident, took her to the dining room. When he returned, he found the first resident unresponsive.

The employee told surveyors that the woman was out of his sight for less than 90 seconds while he took the other resident to the dining room. However, the coroner said the resident had probably been under the water for approximately five minutes.

The facility's residential services director (RSD) told surveyors that it was common practice for staff to remove the resident's helmet and to leave her alone to use the toilet prior to giving her a bath. Following the incident, the RSD said no changes were made regarding staff supervision of clients while bathing and that he saw no need for retraining staff.

The Department-ordered plan of correction required the facility to take all necessary measures to ensure its residents are protected from neglectful situations and to have sufficient qualified staff on duty to meet the needs of residents.

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