Resident Suffers Bone-Deep Infected Wound That Went Undetected Despite Daily Care at The Arc at Sangamon Valley

The Illinois Department of Health has cited and fined The Arc at Sangamon Valley when an 85-year-old resident with diabetes and cognitive impairment developed a severe stage 4 pressure wound that progressed to bone infection due to inadequate skin monitoring and care. The facility failed to properly assess, document, and treat the wound, leading to the resident’s hospitalization and eventual enrollment in hospice care.

The resident in question entered the nursing facility with multiple health conditions including Type 2 diabetes, cognitive impairment, and incontinence, all of which placed her at high risk for developing pressure wounds. Initial assessments confirmed this risk, and care plans were established specifically to prevent skin breakdown through regular repositioning, specialized mattresses, and routine skin monitoring.

However, the facility’s execution of these preventive measures proved inadequate. Daily skin assessments, which should have been conducted during routine care activities like bathing and changing, were either not performed or not properly documented. When staff did complete shower documentation, they often recorded “no wounds” even when wounds were present, indicating either poor observation skills or inadequate examination techniques.

The critical moment came when a nursing assistant noticed a “white patch” while helping the resident with personal care. Upon closer inspection, nurses discovered this was actually a large, open wound on the resident’s left hip area. The wound was immediately concerning due to its size and the fact that it had apparently gone undetected despite daily care activities.

A specialized wound physician was called to evaluate the injury and determined it was a stage 4 pressure wound – the most severe category – with significant dead tissue and signs of infection. The doctor noted that “this wound did not become a stage 4 pressure ulcer in one day” and emphasized that such wounds develop over time through prolonged pressure and inadequate care. Multiple surgical procedures were required to remove dead tissue, with the physician having to cut away infected material down to the bone level.

Throughout the treatment process, serious problems emerged with the facility’s wound care management. Staff members gave conflicting accounts of the wound’s location, with some insisting it was on the right side when medical records clearly documented it on the left. Others confused the wound’s position, alternately describing it as being on the tailbone area versus the hip bone area. This confusion about basic anatomical locations raised questions about staff competency and training.

Medical orders for wound cultures – essential tests to identify infection-causing bacteria and guide antibiotic treatment – were repeatedly not carried out or results were lost. The wound specialist stated she asked for culture results “for 3 weeks in a row and never received a result,” forcing her to prescribe antibiotics without knowing which specific bacteria were causing the infection. When cultures were eventually performed, they revealed serious bacterial infections that required targeted antibiotic treatment.

The facility also failed to consistently provide ordered treatments. Documentation showed multiple dates when prescribed wound care was not administered, leaving the resident without necessary medical attention. Staff members admitted to investigators that they had “issues with skin assessment” and acknowledged problems with nursing documentation and follow-through on medical orders.

As the wound worsened despite treatment, the resident began experiencing severe pain that could not be adequately controlled at the nursing facility. Family members reported that staff responded inappropriately to the resident’s distress, with one nurse allegedly telling the resident in a sarcastic tone that she “would be glad to send you to the hospital” when the resident expressed her pain and desire for better care.

The resident was eventually hospitalized for pain management and treatment of what doctors determined was bone infection caused by the pressure wound. Hospital imaging revealed that the infection had spread into the bone itself, a serious complication that can be life-threatening. Medical staff noted the resident had developed sepsis – a dangerous body-wide response to infection – requiring intensive treatment.

Upon returning to the nursing facility, the resident was enrolled in hospice care, indicating that her condition had deteriorated to the point where comfort care rather than curative treatment was most appropriate. The wound specialist emphasized that the pressure wound was completely preventable, stating “every single wound is avoidable unless a resident is actively dying, and [the resident] was not actively dying.”

The investigation revealed that this incident was not an isolated case of poor documentation, but rather reflected systemic problems with the facility’s approach to skin care and wound prevention. Staff interviews showed confusion about basic medical concepts, inconsistent implementation of care plans, and inadequate supervision of nursing practices. The facility’s response included retraining all nursing staff on wound assessment, anatomical identification, and proper documentation procedures.

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.