June 23, 2004

SPRINGFIELD, Ill. – The Illinois Department of Public Health has fined Ambassador Nursing Center $5,000 (Statement of Violation - PDF) for failure to prevent a resident from leaving the facility unsupervised. The 190-bed skilled care facility is located at 4900 N. Bernard St. in Chicago.

Responding to a complaint, Department surveyors learned a resident left the facility unnoticed and was found about 4.5 miles away outside a hospital emergency department. The temperature at the time was 10 degrees Fahrenheit and the resident was only wearing a T-shirt, pants and sandals with no socks. The resident was treated for frostbite.

When staff realized the resident was missing, they began a search of the building. About 50 minutes later, a police officer called the facility and informed staff that the resident was at the hospital.

The resident, who was fitted with an electronic monitoring device, told surveyors she left the facility by walking through the front door. Staff said they did not hear a door alarm at the time of the incident.

A Department-ordered plan of correction required the facility to provide adequate supervision and to train staff on appropriate actions and interventions to prevent a resident from leaving the facility unsupervised.

Ambassador Nursing Center has requested a hearing on the Department's action. No hearing date has been set.