May 23, 1997

SPRINGFIELD, IL — Bloomingdale Pavilion has been fined $10,000 by the Illinois Department of Public Health for failing to properly supervise its residents. The 259-bed skilled care facility is located at 311 Edgewater Drive, Bloomingdale.

Responding to a complaint, Department surveyors learned that on the same morning in March two residents wandered unnoticed from the facility; one of them drowned in a nearby pond. A third resident who was missing was found injured in a stairwell.

On the morning of March 9, staff could not locate an 81-year-old woman, identified as a high risk for wandering, and began a search. The woman was found about an hour later in a pond behind the facility floating face down in about two feet of water. She was pronounced dead at a nearby hospital.

Earlier the same morning, a 72-year-old male resident could not be located. Police discovered the man at an intersection more than a half-mile from the facility wearing only a hospital gown and socks. The man's feet were bleeding and he had to be given warm liquids to bring up his body temperature.

Also that morning, while searching for the man, employees of the facility found a 93- year-old female resident face down in a stairwell. Her wheelchair was overturned and she had sustained a cut, bumps and bruises.

During an inspection of the facility, Department surveyors noted that all exterior doors leading outside from the stairwells were not equipped with a signaling device that would alert staff if a resident left the facility. The stairwell door where the woman fell had an alarm that would sound, but the alarm shut off automatically when the door closed and did not require staff intervention to disengage it.

In addition, a review of staffing records found that the facility did not have the minimum employees necessary to meet the individual care needs of the residents. The facility administrator told investigators a head count was not done on the day the incidents occurred because staff was busy doing paperwork. Department surveyors also noted that the facility did not have a system in place to supervise residents at risk of wandering and that care plans for possible wanderers were vague.

As part of a mandatory plan of correction, the Department ordered Bloomingdale Pavilion to have an up-to-date plan of care for each resident and to evaluate the facility's door alarm system.

Illinois Department of Public Health 535 West Jefferson Street Springfield, Illinois 62761 Phone 217-782-4977 Fax 217-782-3987 TTY 800-547-0466 Questions or Comments