Arcadia Care On The Hill Cited After Delayed Scheduling of Resident’s Urgent Foot Surgery Allegedly Contributed to Greater Amputation Due to Spreading Infection

The Illinois Department of Health has cited and fined Arcadia Care On The Hill in Springfield, Illinois when, according to state investigators and facility records, the resident’s podiatrist reported that the facility failed to return his repeated calls over the course of approximately a week as he attempted to schedule an urgent foot surgery for a diabetic resident whose infected wound had progressed to expose bone. The podiatrist later told investigators that when the surgery was ultimately performed, more of the resident’s foot had to be amputated than would have been necessary if the procedure had taken place earlier.

The resident was an 83-year-old man with type 2 diabetes, a history of multiple foot surgeries including a prior toe amputation, and a long-standing diabetic foot wound. He had been hospitalized for a serious MRSA bloodstream infection associated with his diabetic foot infection, and after discharge was on a six-week course of intravenous antibiotics through a chest line. Records from the facility document that his left foot wound progressively worsened over a period of weeks — measurements grew larger at each assessment, and at one point investigators reviewed the wound and observed an area larger than a fifty-cent piece with bone visible to the naked eye.

According to the podiatrist’s account to investigators, when he saw the resident at his wound clinic he identified that the wound was increasing in size, the bone was now visible, and the podiatrist stated the resident needed surgery urgently to try to prevent further loss of foot tissue or progression to sepsis. He stated he called the Director of Nursing’s number, faxed orders to the facility, and over the following week made multiple attempts to schedule the surgery. The podiatrist told investigators in his own words: “I called the facility over six times because his bone is hanging out and on top of that he has osteomyelitis and he needs surgery to prevent this guy from losing more of his foot or worse yet, him developing sepsis and dying. Nobody is calling me back. Staff from my office were calling as well. I called, I would leave a message, and no staff member ever returned my message.” The podiatry clinic’s registered nurse confirmed the timeline, telling investigators they attempted to call the facility on multiple specific dates over the course of approximately a week before finally reaching the Assistant Director of Nursing.

Once the call was finally returned, additional time passed before the surgery could be performed. The podiatrist told investigators that when he ultimately performed the surgery, he had to remove more of the resident’s foot than would have been necessary if the procedure had occurred earlier. He stated: “I do believe that if the surgery had been done earlier, I could have saved more of his foot. Again, it puts the resident at risk for more infection and if he gets septic he could easily die. If the surgery had been performed at the end of March, beginning of April, I believe we would have had a better outcome.”

Investigators also identified failures in the administration of the resident’s intravenous antibiotic. The resident had been prescribed daptomycin to be given every 24 hours through his chest line. According to the resident’s medication administration record, the antibiotic was not administered on three documented dates and was administered outside the prescribed time window on five additional dates. The Director of Nursing acknowledged that if the medication administration record was blank for a given dose, the dose had not been given. The Assistant Director of Nursing told investigators directly: “There are holes in his MAR and if it was not charted then it was not done. Basic nursing 101. If there is no record of care documented, then it was not done.” The podiatrist told investigators he had not been informed that the resident was missing antibiotic doses, and stated that missed doses contribute to wound infection progression.

When investigators asked facility leadership about the surgery delays, the Administrator stated she had not received any phone calls or messages about the resident needing surgery and was not aware of any delays. The Assistant Director of Nursing also initially said she was not aware of any delays. A certified nursing aide working as a receptionist confirmed to investigators that the podiatrist had repeatedly called the facility, that calls had been put through to the previous Director of Nursing, and that the podiatrist had eventually told her he would call Public Health if he could not reach facility leadership. According to staff interviews, the wound nurse position had been vacant for approximately a month, and no one had been consistently coordinating wound care or follow-up during that period.

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