June 22, 2004

SPRINGFIELD, Ill. – Fox River Pavilion has been fined $25,000 (Statement of Violation) by the Illinois Department of Public Health for failure to properly monitor a resident identified as a suicide risk. The 121-bed skilled care facility is located at 400 E. New York St. in Aurora.

As part of an incident report investigation, Department surveyors learned a resident crashed through his bedroom window and landed on a roof two stories below. The resident, who was admitted to the facility the day before, was pronounced dead at a local hospital.

The resident's physician had instructed staff to implement suicide precautions and monitor the resident every two minutes. The administrator, however, told surveyors the facility was not equipped to care for a resident considered at risk for suicide and, instead, he should have been admitted to a hospital.

Department surveyors learned the facility did not to follow its suicide prevention policy, which stipulates residents at risk for suicide should be located, if possible, on the first floor and never left alone. The resident's fourth-floor room was the furthest from the nursing station.

The policy also states the facility would not accept a resident with a previous history of being at risk for suicide unless a doctor documented the resident is no longer suicidal.

A Department-ordered plan of correction required the facility to take all necessary precautions to assure the residents' environment remains free of hazards; to educate staff in their role of providing care to and monitoring of residents with histories of confusion and suicidal ideations; and to implement a policy for admission of residents to the facility, including whether the required care is within the scope of the facility.

Fox River Pavilion did not request a hearing on the Department's action.