SPRINGFIELD, Ill. – Boxwood Health Care Center has been fined $5,000 (Statement of Violation - PDF) by the Illinois Department of Public Health for failure to prevent a resident from leaving the facility unsupervised. The 60-bed skilled care facility is located at 418 S. Memorial Park Drive in Newman.

During an incident report investigation, Department surveyors learned a resident, who had a history of wandering, left the facility unnoticed and was driven 15 miles to his home by a stranger.

When staff called the resident's family to notify them he was missing, the resident answered the phone and said he was home alone and did not know how he got there. Staff picked up the resident and returned him to the facility unharmed.

Because of his frequent attempts to leave the facility, the resident's care plan required staff to monitor the resident every 15 minutes. The nurse's aide initialing the log the day of the incident said she did not see the resident each time she recorded an entry, but was dependent on other staff to help verify the resident's location. The way the log was set up, as much as 30 minutes could lapse between checks.

On the day of the incident, the resident told staff he wanted to leave the facility and walk home. Staff noted that the resident was wearing his coat and walking up and down the hallways. He had to be redirected from leaving the building several times.

A Department-ordered plan of correction directed the facility to review its policies on assessment, care planning, door alarms and elopement; to train staff on appropriate actions and interventions to prevent a resident from leaving the facility unsupervised; and to assess each resident who wanders to identify their level of safety awareness.

Boxwood Health Care Center has requested a hearing on the Department's action. No hearing date has been scheduled.