Wednesday, November 19, 2008

St. Paul's House and Health Care Center Fails to Prevent Patient from Wandering

3800 N. California Ave. in Chicago
FINED- December 13, 2002
St. Paul's House & Health Care Center was fined
$5,000 for failure to prevent a resident from leaving
the facility unsupervised.
Subsequent to an incident report investigation,
Department investigators learned an elderly resident,
who had a history of wandering and wore an electronic
monitor, left the facility unnoticed and was found by
an off-duty employee about six blocks away. The woman
was returned to the center unharmed.
Staff members had taken a group of residents, who
live in a secured unit on the second floor, to the
first floor auditorium to participate in a scheduled
activity. When staff returned the residents to the
second floor 30 minutes later, the woman was no longer
among the group. A search of the facility failed to
locate her.
Facility staff told surveyors they believe the
resident left through the auditorium exit doors, which
were not equipped with an audible alarm. Surveyors
determined that none of the 13 exit doors on the first
floor had an audible alarm and an employee entrance
was the only door equipped with a sensor to detect
electronic monitors.
A Department-ordered plan of correction required the
home to provide residents with adequate and properly
supervised nursing care and to ensure all
resident-accessible exterior doors are equipped with
functional alarms or are monitored by constant visual

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