January 16, 1998
PEORIA NURSING HOME FINED FOR NOT ENSURING RESIDENT SAFETY
SPRINGFIELD, IL Sharon Health Care Willows has been fined $10,000 by the Illinois Department of Public Health for not providing adequate supervision and oversight of bed rail use to ensure resident safety. The 219-bed intermediate care facility is located at 3520 N. Rochelle in Peoria.
An investigation was begun after the Department received a report from the facility of an 88-year-old resident who died due to a broken neck. The woman was found on the floor of her room with her head trapped between the bed's metal frame and the side rail.
Department surveyors learned that on the night of her death, there was a staff shortage and only one employee was available to provide care for 47 residents in two wings. The woman was checked at 8:20 p.m., but not again until she was found dead about 11 p.m.
Surveyors also found the facility recently replaced the full-length side rail on the resident's bed with a half side rail, but did not keep manufacturer product installation and safety guidelines. Without the product information, staff could not determine if the side rails were appropriate for use by the woman or for nine other residents who had the same side rails.
of Public Health
535 West Jefferson Street
Springfield, Illinois 62761
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