Aperion Care Dekalb Fails to Follow Daily Wound Care Orders Leading to Amputation and Life-Threatening Infection

The Illinois Department of Health has cited and fined Aperion Care Dekalb when staff failed to follow a wound specialist’s orders for daily wound packing on a resident’s infected surgical site, instead providing care only three times per week. The facility’s negligence allowed a serious infection to develop into osteomyelitis and an abscess, requiring emergency hospitalization, surgical washout procedures, and ultimately resulting in the resident’s leg being amputated below the knee.

The resident in question had undergone knee surgery earlier in the year and was recovering at the nursing home when his surgical wound began showing signs of infection. The wound specialist overseeing his care had prescribed specific treatment protocols designed to promote healing and prevent the type of serious complications that ultimately occurred. The resident was already colonized with MRSA (Methicillin-resistant Staphylococcus aureus), a dangerous antibiotic-resistant bacteria, making proper wound care even more critical to prevent infection.

The Wound Nurse Practitioner who had been following the resident’s case explained the progression of his condition, stating that his “surgical incision started off as covered eschar” and “one side of the eschar had tunneling underneath with some slough.” Initially, there were “no signs or symptoms of infection, but then the wound had some drainage” and “the tunneling appeared worse.” When an x-ray was ordered “to rule out osteomyelitis,” it “came back suspicious for osteomyelitis,” prompting her to send the resident to the hospital immediately.

The critical error occurred in how the facility interpreted and implemented the wound care orders. The Wound Nurse Practitioner was adamant about the importance of daily treatment, stating “wound packing is almost always done daily in order to be effective” and “I never order packing a wound only Monday, Wednesday, and Fridays.” She explained that “wound packing helps the wound heal from the inside out and packing wicks the wound drainage out of the wound” and emphasized that “daily packing changes prevents a bacterial bio film from forming in the wound cavity.”

Despite the specialist’s clear intent for daily care, the facility’s transcription of orders repeatedly included the dangerous modification of “Monday, Wednesday, Friday” scheduling instead of daily treatment. Multiple physician orders show this pattern, with the facility consistently adding the three-times-per-week schedule even when the original medical orders called for daily care. The Wound Licensed Practical Nurse confirmed that the facility was following this inadequate schedule, stating that the “treatment orders were packing the wound with iodoform packing on Monday, Wednesday, and Fridays.”

The consequences of this inadequate care schedule were severe and progressive. The wound continued to deteriorate despite treatment, with measurements showing it was getting larger and deeper over time. Medical notes documented the wound “measuring 2.0 x 11.0 x 0.5 cm with moderate sero-sanguineous drainage” and later showing “large serosanguinous drainage with tunneling” at multiple positions. The specialist noted that “the wound is deteriorating” and continued to emphasize the need for daily care in her treatment orders.

The Wound Nurse Practitioner explained the medical risks of the facility’s inadequate care schedule, stating that the “bacterial bio film increases the risk for infection especially someone already colonized with Methicillin-resistant Staphylococcus aureus like the resident.” She warned that “not doing daily packing wound dressing changes could cause a delay in healing, increase the risk for infection and lead to deterioration of the wound.” Tragically, all of these complications occurred exactly as she had predicted.

When the resident was finally hospitalized, the extent of the infection was shocking. Hospital records showed “infection of amputation stump/abscess of left lower extremity” and “intra operative cultures showed Enterococcus faecalis, Staphylococcus aureus and Corynebacterium stratum.” A CT scan revealed a “possible abscess measuring 2.1 x 5.1 x 4.0 cm” with “underlying osteomyelitis” confirmed. The resident required immediate surgical intervention with a “washout left below-knee amputations site” and was placed on intensive intravenous antibiotics.

The resident described his ordeal in heartbreaking terms, explaining that he “originally had surgery on his knee back around the Superbowl” but “the wound became infected” despite having “pills and shots and surgery.” He described being hospitalized where “they jabbed him with more needles” and having to undergo amputation surgery. When found during the investigation, he was “in bed with an intravenous antibiotic infusing” and his “left leg was amputated below the knee and was wrapped in a dressing with a wound vacuum attached.”

The facility’s failure was made worse by poor communication and oversight. The Wound Licensed Practical Nurse admitted that he “did not review the wound specialist’s written treatment orders,” relying instead on the facility’s incorrect transcription of those orders. The Wound Nurse Practitioner stated she “was not aware that the resident’s wound packing dressing was not being done daily,” indicating that the facility had not communicated their deviation from her prescribed treatment plan.

This case represents a devastating example of how seemingly minor changes to medical orders can have catastrophic consequences. The facility’s decision to reduce daily wound care to three times per week directly contributed to the development of a serious infection that ultimately required amputation of the resident’s leg, transforming what should have been a routine recovery into a life-altering medical emergency that left the resident permanently disabled and requiring intensive ongoing medical care.

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.