SPRINGFIELD, Ill. – Manor Care at Oak Lawn/95th 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 195-bed skilled care center is located at 6300 W. 95th St. in Oak Lawn.

As part of an incident report investigation, Department surveyors learned a resident with a history of wandering died from cold weather exposure after leaving the facility unnoticed. The wind chill index during the nearly two and one half hours the resident was missing ranged from minus 12 degrees to 3 degrees above zero.

On the day of the incident, several employees took their dinner break at about the same time, leaving only a nurse and two nurse aides on the unit. When a nurse aide realized the resident was missing, she began a search, but did not notify a supervisor or other staff for 40 minutes. It was another hour before police were called.

A police officer and a bystander found the resident lying face down on a street. He was admitted to a local hospital and died the following day of bronchial pneumonia and hypothermia.

The resident was outfitted with an electronic monitoring device, but staff did not recall hearing an alarm sound. The alarm system was not checked after the incident to see if it was working.

A Department-ordered plan of correction required the facility to provide adequate supervision; to review and revise, as necessary, policies for resident wandering; and to train staff on appropriate actions and interventions to prevent a resident from leaving the facility unsupervised.

Manor Care at Oak Lawn has requested a hearing on the Department's action. No hearing date has been set.