January 7, 2005
SESSER FACILITY DISCIPLINED AFTER RESIDENT’S DEATH SPRINGFIELD, Ill. – The Illinois Department of Public Health has fined Redwood Manor $25,000 (Statement of Violation) for failure to adequately supervise a resident at risk for suicide. The 58-bed intermediate care facility is located at 802 W. Franklin St. in Sesser. Responding to a complaint, Department surveyors learned a resident died after drinking a cleaning disinfectant taken from a janitor’s closet, which did not lock properly. The resident had a history of suicide attempts and was admitted to the facility by court order after being found unfit to stand trial. Despite his history, the resident’s care plan did not include any suicide precautions. Police were called to the facility by staff about a month prior to the resident’s death because he was threatening to commit suicide and a week later he called 911 to say he was going to commit suicide. When staff found the resident he had vomited and was not breathing. A nurse began cardiopulmonary resuscitation (CPR), but failed to first clear the resident’s airway as directed by facility policy. The police report states that CPR was not being done at the time police arrived. Redwood Manor did not request a hearing.
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Illinois Department
of Public Health 535 West Jefferson Street Springfield, Illinois 62761 Phone 217-782-4977 Fax 217-782-3987 TTY 800-547-0466 Questions or Comments |