Wednesday, February 4, 2009

Manor Care Oak Lawn Resident Freezes to Death After Nursing Home Fails to Monitor Resident

MANOR CARE AT OAK LAWN
6300 W. 95th St. in Oak Lawn.
FINED- June 2, 2004
Manor Care at Oak Lawn/95th was fined $10,000 for
failure to prevent a resident from leaving the
facility unsupervised.
As part of an incident report investigation,
Department surveyors learned a resident with a history
of wandering died from cold weather exposure after
leaving the facility unnoticed. The wind chill index
during the nearly two and one half hours the resident
was missing ranged from minus 12 degrees to 3 degrees
above zero.
On the day of the incident, several employees took
their dinner break at about the same time, leaving
only a nurse and two nurse aides on the unit. When a
nurse aide realized the resident was missing, she
began a search, but did not notify a supervisor or
other staff for 40 minutes. It was another hour before
police were called.
A police officer and a bystander found the resident
lying face down on a street. He was admitted to a
local hospital and died the following day of bronchial
pneumonia and hypothermia.
The resident was outfitted with an electronic
monitoring device, but staff did not recall hearing an
alarm sound. The alarm system was not checked after
the incident to see if it was working.
A Department-ordered plan of correction required the
facility to provide adequate supervision; to review
and revise, as necessary, policies for resident
wandering; and to train staff on appropriate actions
and interventions to prevent a resident from leaving
the facility unsupervised.

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