The Illinois Department of Health has cited and fined Evercare of Swansea when two residents with serious mental health conditions walked away from the facility unnoticed, with one found alone in a parking lot after the staff had no idea she was missing. The facility failed to implement basic safety measures despite assessments clearly showing both residents were at high risk for leaving and unsafe to be outside alone.
A 74-year-old woman with schizophrenia and confusion was admitted to the facility after being found at an airport claiming she had been kidnapped. Hospital records described her as having “delusions and paranoia” and noted she had been placed on “elopement precautions” during her hospital stay. Her brain scan showed permanent damage that caused memory loss and impaired judgment.
When the facility assessed her upon admission, she scored a 6 on their elopement risk evaluation, where any score of 1 or higher indicates risk. Another assessment concluded she “does not appear to be capable of unsupervised outside pass privileges at this time,” noting she didn’t know the facility’s address, couldn’t ask for help in an emergency, and wouldn’t know to sign out before leaving.
Despite these clear warnings, the facility took no meaningful action to protect her. Staff members consistently documented her confusion and exit-seeking behavior, with notes describing how she “attempted several times to leave facility” and wandered into other residents’ rooms at night. One nurse wrote that the resident “approached side doors several times during the shift.”
The morning she disappeared, her nurse noted she was “carrying some of her belongings around in bags, and stated she was leaving.” Yet nobody implemented the enhanced supervision measures the facility’s own policy required for high-risk residents.
The resident simply walked out of the building without anyone noticing. The facility had no idea she was gone. A nursing assistant returning from lunch spotted her about 20 minutes later, standing alone in an apartment complex parking lot roughly two-tenths of a mile from the facility. “I saw her down the street,” the assistant explained, describing how she made a U-turn, picked up the confused resident, and brought her back.
When facility leadership was asked how long the resident had been missing, the administrator guessed “approximately 5 minutes” based on a timeline she created, though she admitted someone likely “deactivated the door alarm without checking to see why it went off.”
The resident received no medical evaluation after being found wandering outside alone, despite her serious mental health conditions and the risks she faced. Staff simply told her to remember to sign out next time, even though multiple employees acknowledged she was too confused to understand that requirement. Her care plan was never updated, and no additional safety measures were put in place. Two days later, her family removed her from the facility.
When investigators began asking questions, facility leadership initially refused to acknowledge this qualified as an elopement. The administrator said she “did not report the elopement” because the resident had scored well on a basic cognitive test. When pressed about the resident’s other assessments showing she was unsafe to leave alone, the Vice President of Clinical Services responded, “I am confused at times, and residents still have rights.”
Investigators discovered the facility had never scheduled the follow-up appointment at a memory diagnostic center that hospital doctors had ordered, with the administrator explaining “the prior transport aide quit with no notice.” The facility also failed to take a photograph of the resident or create an elopement risk binder as required by their own policy, despite clear documentation she was at high risk.
Less than a month later, a second resident with paranoid schizophrenia and a documented history of elopement from his previous facility walked away and was gone for over three hours. This man had transferred from another nursing home where he required one-on-one supervision specifically because of elopement. When he arrived at this facility, staff never completed his cognitive assessment on time, never took his photograph, and never created an elopement binder.
One the day of the incident the resident’s nurse happened to be an agency worker who had cared for him at his previous facility and knew about his elopement history. Between mid-morning and 10 AM, she became concerned when she couldn’t find him and began searching. Multiple staff members ran through the hallways looking for him in what investigators described as “an uncoordinated manner,” while exit door alarms kept sounding “on an ongoing basis with slow response time by staff.”
He wasn’t found until after noon, when a transportation aide spotted him walking back toward the facility. He told staff he had jumped the fence, walked downtown to a fountain about a mile away, and visited various places trying to get titles and tax documents. When investigators interviewed him the next day, he couldn’t remember where he’d gone but mentioned he planned to “just take the bus” the next time he left.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
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