The Illinois Department of Health has cited and fined Highlight Healthcare of Aurora when staff failed to perform ordered dressing changes on a resident’s surgical amputation site for five days, resulting in the wound becoming infected and infested with maggots. The resident required emergency hospitalization, critical care treatment, intravenous antibiotics, and surgical debridement under general anesthesia.
A resident with multiple serious health conditions had surgery to amputate three toes on her right foot due to gangrene. After a brief hospital stay, she returned to the facility with instructions to leave the dressing in place until her follow-up appointment one week later.
At the follow-up, the surgeon found the wound “looked very good” – a closed surgical site with no opening, drainage, or swelling. He ordered wound cleansing and dry dressing changes every other day, along with antibiotics to prevent infection. A facility nurse called to confirm the orders.
Despite these clear orders, no dressing changes were documented for the next five days. The Treatment Administration Record showed no treatments completed during this period, and progress notes contained no documentation of any assessment of the surgical site.
A nursing assistant noticed something unusual on the dressing – “dark in color, something unusual that you would not see on a sock. It did not really look like blood.” He alerted the nurse, who found the bandage saturated with brown drainage and a strong odor. As she unwrapped it, the resident cried out in pain. The nurse saw maggots on the bandage, immediately called the doctor, and the resident was sent to the emergency room. The nursing assistant later found eight to ten more maggots on the bed linens.
The emergency department physician documented “wound dehiscence, necrotic tissue, copious maggots cleaned from wound” and noted the wound had split open with dead tissue and numerous maggots. The resident was admitted for “suspected osteomyelitis, need for IV antibiotics, and risk of clinical deterioration.” The emergency doctor provided forty minutes of critical care due to “high-risk for rapid clinical deterioration due to potential progression to severe sepsis or septic shock.”
The surgeon performed emergency surgery under general anesthesia. His notes documented “the sutures were still in place, however they were not holding any skin or flaps at this time…several dead bodies of maggots were noted…bony exposure is noted in the wound site.” He had to remove all dead tissue and maggot remains.
The surgeon explained: “When I saw her for the follow-up, the wound was a closed surgical site. It looked very good. The next time I saw her was the day after she was sent to the hospital. The stitches were no longer holding the tissue together. It was an open wound.” He stated directly, “If the facility would have done the dressing changes and monitored the surgical site, it may have prevented the wound from getting infected and infested with maggots, and I would not have had to perform the surgical debridement procedure.”
Investigators discovered the nurse who confirmed the orders “entered the order into the system wrong” – she put it in a section where “the nurses cannot see the order.” The order wasn’t entered correctly until the day the resident was sent to the emergency room. However, the administrator acknowledged that nurses on all three shifts during those five days should have verified orders after the follow-up appointment.
The facility’s wound nurse confirmed he did not perform any dressing changes or assessments because he doesn’t handle residents who go to outside wound clinics. He stated, “There was no dressing change completed, no facility assessment, or measurements that I can tell from the day after the follow-up through the day she was sent to the hospital.”
The resident’s power of attorney said, “The facility staff were supposed to look at her wound every two days. It is just too much. This should not have happened.”
The facility’s medical director stated, “If a resident goes out for wound care and comes back with an order to do dressing changes, the facility nurses should be doing their own wound assessment with every dressing change, document their findings, and notify the physician if there are any changes.”
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