Thursday, November 13, 2008

Imperial Grove Pavilion Fails to Assess Risk Patient Would Leave Nursing Home

1366 W. Fullerton Ave. in Chicago
FINED- 2002
The Imperial Grove Pavilion was fined $10,000 for
failure to properly assess a resident for risk of
leaving the facility.
Responding to complaints, Department surveyors
learned a wheelchair-bound resident sustained numerous
injuries, including head trauma, several fractures and
cuts, when she fell down a flight of stairs while
attempting to leave the facility. The resident was
taken to a local hospital for treatment after a nurse
found her lying in a stairwell.
About a week prior to the incident, the resident had
become agitated and, on several occasions, was
observed trying to leave the floor via the elevator
and the stairs. The resident's physician told
surveyors that, five days prior to the incident, staff
told him of the resident's attempts to leave the
Despite this change in behavior, the facility did not
reassess the resident's care plan or implement steps
to more closely supervise the resident to prevent her
from leaving the facility.
The Department-ordered plan of correction required
the facility to provide adequate supervision of
residents, to document changes in residents'
conditions and to ensure staff are aware of the level
of care required by each resident.

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