April 23, 1999

SPRINGFIELD, IL - Villas of Shannon has been fined $10,000 by the Illinois Department of Public Health for failing to properly supervise a resident who twice wandered unnoticed from the facility this winter and on one occasion was found walking in the snow without shoes. The 73-bed intermediate care facility is located at 418 S. Ridge St., Shannon, in Carroll County.

Responding to incident reports, Department surveyors learned that the 80-year-old woman left the facility two times in January without the staff's knowledge. The first time, on Jan. 7, she was discovered on a nearby street wearing a dress and light sweater. The temperature was estimated at minus 5 to minus 10 degrees. Five days later, a passerby noticed the woman at the end of a street four blocks from the facility wearing only a gown and no shoes. On that day, the street and sidewalks were snow covered, the temperature was 9 degrees and the wind chill was minus 19. The woman was treated for large blisters and swelling on her feet.

During a review of other resident files, Department surveyors found two other residents at risk for wandering who did not have care plans designed to prevent elopement or instructions instructions on how they should be monitored to ensure their safety. All residents identified at risk for wandering are to have written procedures in place designed to address that behavior possibility.

As part of a mandatory plan of correction, the Department ordered the facility to instruct staff on search procedures when a resident is reported missing, and on the importance of responding to door alarms and to ensure all doors are equipped with an audible signal to alert staff when a resident exits the building. (Statement of Violation)

The facility has requested a hearing on the Department's action. A hearing date has not been scheduled.

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