The Illinois Department of Public Health has fined a Bloomington nursing home $25,000 for letting a 49-year-old woman with dementia wander away from the facility in stockinged feet.
Video footage detailed in the report shows the woman leaving Aperion Care through an emergency exit facing Calhoun Street one evening last March. The temperature at the time was 41 degrees. She did not have a coat.
A nurse on the clock that night said she did not remember hearing the emergency door alarm going off, or having reset it, according to state records. The report explained the alarm is both audible and visual, with a panel on the wall lighting up to signify which door was opened.
When an alarm sounds, staff are supposed to check the alarm panel to see which door was opened then check outside of the door for any residents that could have exited, the report explains.
Video footage shows the patient leaving her room and exiting the emergency door at 7:06 p.m.
The report states the alarm has to be turned off manually. A second nurse said, “staff probably heard the alarm and thought it was one of the smokers going out to smoke and just ignored it.”
“The residents have a smoke break at 7:00 p.m. and the alarm constantly rings during this time,” a nurse stated in the report.
According to the report, video footage shows nurses realized the woman was missing less than 10 minutes after she walked out, but no one checked out of the emergency exit door until a nurse was “bringing in the smokers” at 7:30 p.m., nearly 25 minutes after the woman left the facility.
The 49-year-old was found an eighth of a mile away from Aperion at a residential property and taken to the hospital. The report details the woman complained that her feet hurt because of the cold.
She was returned to Aperion Care by 9:50 p.m.
The state alleged Aperion workers did not know the woman was a risk to wander and was not on a list for prevention protocols even though that was in her paperwork when she was transferred to the facility the day of the incident. And four days after the incident, the woman was still not listed among the “Elopement Risk Residents,” or residents who are likely to wander.
The notice of violation and the fine is the start of a process during which nursing homes typically contest the initial finding and then make adjustments to their policies, procedures, and training, before a final ruling and sometimes a lesser fine comes out.
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