SPRINGFIELD, Ill. -- Stephenson Nursing Center has been fined $5,000 (Statement of Violation) by the Illinois Department of Public Health for failure to prevent a resident from leaving the facility unsupervised. The 162-bed skilled and intermediate care facility is located at 2946 S. Walnut Road in Freeport.

During an investigation, Department surveyors learned a resident, who had a history of wandering, climbed over a 4-foot fence outside the unit where he resided and walked along a country road to a racetrack about a mile from the facility. About one hour after he was last seen at the facility, a racetrack official called Stephenson Nursing Center to say the resident had been observed at the racetrack. A sheriff's deputy returned the resident to the facility unharmed.

There were only two aides working the unit on the night of the incident even though three residents required one-to-one supervision. After one aide left for a break, there was about 40 minutes when only one aide was present to assist 22 residents.

On the night of the incident, the resident went outside and had to be brought in by an employee. When the employee noticed the resident was not sitting where she left him, she assumed he had gone to bed. The nurse on duty also noticed he was not sitting in front of the television and assumed he was in bed.

A Department-ordered plan of correction required the facility to ensure that there is adequate staff present to meet the residents' needs and to equip all exterior doors with an audible signal to alert staff when a resident leaves the building.