September 27, 1995
TWO COOK COUNTY NURSING HOMES DISCIPLINED
SPRINGFIELD, IL -- The Illinois Department of Public Health has taken disciplinary action against two Cook County nursing homes:
GAF Lake Cook Terrace was fined $10,000 for failure to adequately monitor and supervise a 50-year-old resident who had a history of wandering.
The resident was missing for nearly four hours in the early morning before she was found outside the facility suffering from hypothermia and had abrasions on the back, forearm and thigh. She also had wandered from the facility the week before and was found in front of the building with her hands and feet covered with mud.
Her care plan, which was not updated after she wandered outside the first time, called for her to be checked frequently, kept in view and in a safe environment, and observed for behavior changes.
Villa Scalabrini Home was fined $10,000 for inadequate supervision and failure to use safety devices properly.
Responding to a complaint, Department surveyors determined a 79-year-old resident, wearing a physician-ordered vest restraint, was found not breathing with her head lodged between the side rails and mattress. The medical examiner reported the resident died of asphyxia due to faulty placement of a restraint.
The restraint was tied to the right and left sides of the bed frame, although the restraint manufacturer warns not to use any side rails that would allow the resident's body or limbs to fit between the side rails because the resident may become suspended in the restraint and suffocate.
Staff also was to check the resident every hour throughout the night, but, according to nurses notes, the resident had not been seen for approximately 90 minutes when she was found to be not breathing.
Villa Scalabrini administrators were ordered to review the facility's policy and procedures for supervision and safety of residents and to hold mandatory education classes to ensure staff know the proper ways to provide resident care and supervision.
Both facilities have requested hearings on the Department's action. No hearing dates have been set.
of Public Health
535 West Jefferson Street
Springfield, Illinois 62761
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