Monday, January 19, 2009

Resident of Manor at Lincolnwood Place Dies After Facility Fails to Monitor

MANOR AT LINCOLNWOOD PLACE
7000 N. McCormick Blvd. in Lincolnwood.
FINED- June 7, 2001
Manor at Lincolnwood Place was fined $10,000 for
failure to adequately supervise a resident with a
history of wandering.
Responding to an incident report, Department
investigators learned a resident left the facility
unnoticed about 2 a.m. and was found the next morning
face down in the snow between two vehicles in an
automobile dealership parking lot which is about 1,000
feet from the facility. The woman was transported to a
local hospital emergency department where she was
pronounced dead from hypothermia.
The resident, who had been missing for about six
hours, was dressed only in a housecoat and was not
wearing shoes. The overnight temperature was between 8
degrees and 10 degrees.
Per staff interviews, surveyors found the resident
had been wandering around the facility much of the
previous evening and had to be redirected to her room
several times. While conducting rounds, a nurse -- who
had previously guided the resident back to her room --
noticed the resident was not in her room and a search
of the facility failed to locate her.
It is assumed the resident left through an east exit
door that is also used as an entrance for the
facility's assisted living section. This door requires
a key card to enter the facility, but there is no
alarm on the door or key card required for exit.
A Department-ordered plan of correction required the
facility to ensure that supervision precautions are in
place for residents diagnosed with wandering behaviors
and that all resident-accessible exterior doors are
equipped with an alarm or are visually monitored.

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