The Illinois Department of Health has cited and fined Integrity Healthcare of Marion when a resident developed severe pressure ulcers on both heels that were inadequately treated, leading to sepsis, gangrene, and bone infection. The resident ultimately required emergency surgery to remove both Achilles tendons and heels before dying on hospice care.

The resident in question was admitted to Integrity Healthcare of Marion with multiple medical conditions including Parkinson’s disease, diabetes, hypertension, and peripheral vascular disease. According to facility records, he initially had no heel ulcers when he returned from a hospital stay in January.

The first heel ulcer was discovered in March when the resident’s daughter noticed blood coming through his white socks. A nurse found a large wound on his right heel measuring approximately 6 centimeters by 5.8 centimeters. The facility’s wound specialist began weekly treatments involving debridement (removal of dead tissue) and various dressings.

A second ulcer developed on the left heel, though facility records show no documentation of when this wound was first identified or initially assessed. The wound specialist’s notes indicate both areas were classified as “arterial wounds,” though the surgeon who later treated the resident determined they were actually pressure ulcers caused by inadequate pressure relief.

Over the following months, both ulcers showed signs of severe deterioration despite weekly specialist visits. The wounds developed thick black tissue (eschar), required repeated surgical debridement of dead bone and muscle, and began producing a foul odor. Staff members reported that “you could smell it as soon as you walked into his room.” Family members complained about the smell, but were told by facility staff that it was caused by the medications being used to treat the ulcers.

The facility’s care plan included various interventions such as a special air mattress, heel protector boots, and wound treatments. However, multiple staff members reported that the heel protector boots were often missing or not in place when they came on duty. One family member stated: “when she visited him, they would be off, and she would put them back on… one day they were gone… when she asked about them, they told her they were in laundry, and they just never came back.”

Critical gaps in care were documented throughout the resident’s stay. There were no physician orders found for treating the right heel ulcer for two weeks after it was discovered. The facility’s weekly skin assessments failed to document the heel ulcers on multiple occasions, simply noting “no new areas” or “no changes to current wounds.” Despite the wound specialist’s notes indicating he was debriding infected tissue and bone, no wound cultures were ordered until late in the treatment process, and no antibiotics were prescribed specifically for the heel infections.

The resident’s condition deteriorated significantly in May. He became lethargic, stopped eating properly, and developed fever and low blood pressure. When finally sent to the hospital, he was found to be in sepsis with multiple bacterial infections. CT scans revealed extensive tissue death, gas in the tissues, and bone infection (osteomyelitis) in both heels.

The consulting surgeon described finding heels that were “completely rotted up to the Achilles tendon” with infection that had tracked up the leg. She stated: “basically [the resident] was ‘circling the drain’ when he came to the hospital… was so bad, the question was how he got that bad and no one saw it.” The surgeon noted that “the smell of gangrene was so powerful when [the resident] arrived at the hospital, there was no way the facility could have thought he was ok.”

During emergency surgery, both Achilles tendons and heel areas had to be removed. The resident never recovered from the surgery, was placed on hospice care, and died several days later.

The surgeon who treated the resident concluded that the ulcers were preventable pressure wounds, not arterial wounds as classified by the facility’s wound specialist. She found that the resident had normal blood flow and stated the wounds were caused by inadequate pressure relief: “Yes, [they were preventable] as long as someone was floating the heels.” She noted there was “no form of off-loading the heels” and that while “heels can get that bad… not that quickly.”

The investigation revealed systemic failures in the facility’s pressure ulcer prevention and treatment protocols, inadequate monitoring and documentation, and insufficient implementation of prescribed interventions that ultimately contributed to the resident’s death.

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.

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.

The Illinois Department of Health has cited and fined Plymouth Place when staff failed to properly assess, document, and report a resident’s worsening toe wounds for over three months, resulting in gangrene that required a full above-knee amputation of the resident’s left leg just one day after being transferred to another facility.

The resident in question suffered from multiple serious health conditions, including congestive heart failure, chronic obstructive pulmonary disease (COPD), respiratory failure, difficulty walking, and depression. Though cognitively intact, he required substantial assistance with most daily activities including toilet hygiene, showering, dressing, personal hygiene, and bed mobility. He was completely dependent on staff for transfers between surfaces, had an indwelling urinary catheter, and was always incontinent of stool.

From the day after his admission, the facility documented that the resident had wounds on his left toes. His care plan noted “Site: LT (Left) great toe scab. LT 2nd toe scab” and included interventions to “Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to MD.”

The facility’s Wound Care Nurse, a Licensed Practical Nurse (LPN), assessed the resident’s left toe wounds regularly for over three months. However, her documentation had serious deficiencies. She consistently referred to wounds on the “left toes” without differentiating which specific toes were affected. She recorded the same exact measurements—1 centimeter by 1 centimeter—for every assessment over the entire three-month period, rather than measuring each affected toe separately. There was no evidence she ever notified the resident’s physician about these wounds.

Most concerning, the Wound Care Nurse documented that the wounds, which she initially described as improving, had “stalled” in their healing about a month before the resident’s discharge. Despite this change in status, she still did not notify the resident’s physician. The facility Administrator later acknowledged that the nurse “should have documented separate wound measurements for each toe, as well as the appearance of each wound separately. There is no documentation to show she spoke to the Attending Physician, or that he was aware of the wounds.”

The resident’s attending physician saw him multiple times during this period for “wound care follow for superficial wounds” and “wound care as needed,” but his notes never specifically mentioned the left toe wounds. The physician later stated, “I depend on wound nurses and facility staff to do their job… If that changed, they should have notified me.”

After about three months at the facility, the resident was transferred to a different nursing facility. The Discharge Summary noted “Skin Intact: No,” indicating he still had skin issues, but no wound assessment was completed as required by the facility’s own form. The nurse who handled the discharge admitted, “I did not see the resident’s feet the day of his discharge from the facility. He wore shoes. He always wanted them on.”

A Certified Nursing Assistant who cared for the resident on his last day at the facility provided concerning information: “A couple of days before, his toe looked black on his big toe. The last couple of days it was dark. I reported it to the nurse, but she said it was already reported.” The assistant added that the resident “liked to keep his socks on because he said his feet were always cold, so we left his socks on.”

Most disturbingly, the Wound Care Nurse admitted to falsifying documentation, stating: “I did not actually see the resident’s toes on the day of his discharge. I did not do wound care on him the day he left even though I signed that I did it. I documented that I did his wound treatments, but I actually did not do the wound care treatments that day. He was gone from the facility by the time I got to him.”

Just one day after being transferred to the new facility, the resident was rushed to the hospital. A Vascular Surgery Nurse Practitioner documented that the resident “presents with ischemic left toes… gangrene left toes (1st through 3rd, starting to spread to 4th/5th).” The Nurse Practitioner noted they were “unsure of how long have been like that” but that the “family noted foul smell for over a week.”

A hospital podiatrist evaluated the resident and determined: “Given the amount of tissue loss and necrosis, a midfoot or proximal foot amputation is unlikely to heal and to be functional.” The resident and his family agreed to a more extensive amputation. Two days after admission to the hospital, the resident underwent a left above-the-knee amputation of his entire leg. Following surgery, his condition deteriorated, and he was admitted to the intensive care unit.

The resident’s physician later stated, “It is unlikely that someone would go from a one centimeter wound to full gangrene in a day. It is unlikely that gangrene would come in one day, especially with an odor.” He placed blame on the facility staff, saying, “These failures resulted in the poor outcome for the resident, requiring a leg amputation. That is not appropriate support or care for someone who comes to a facility.”

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.

The Illinois Department of Health has cited and fined Generations At Applewood when staff failed to perform required weekly skin assessments on a dependent resident who developed multiple severe pressure ulcers while in their care, ultimately resulting in a stage 4 sacral wound with necrotic tissue that became infected and required hospitalization and six weeks of intravenous antibiotics.

The resident in question was admitted with multiple medical conditions, including local skin infection, difficulty swallowing, peripheral vascular disease, hypothyroidism, gastroesophageal reflux disease, and chronic kidney disease. According to facility records, the resident developed three pressure ulcers (also known as bedsores) after her admission – a stage 3 ulcer on her right elbow, a stage 4 ulcer on her left leg, and a stage 4 ulcer on her sacrum (lower back).

The sacral wound was particularly severe. A wound assessment note described it as a “stage 4 pressure wound” that was “full thickness” with a size of “8.0 x 15.5” centimeters. The depth was noted as “unmeasurable due to presence of nonviable tissue and necrosis.” In other words, the wound was so deep and filled with dead tissue that its true depth couldn’t be determined.

The resident’s condition deteriorated to the point where she needed hospitalization. Hospital records indicated she was admitted from the nursing home with “pressure ulcer on the right elbow and worsening of sacral decubitus ulcer with foul smell draining pus.” The infection was serious enough that she required intravenous antibiotics (Vancomycin and Zosyn), a surgical consultation, and planning for surgical debridement (removal of dead tissue). The hospital determined she would need “more than 2 medically necessary midnights of in-hospital care because of sacral decubitus ulcer infection” and planned for her to continue antibiotics for a total of six weeks after returning to the nursing home.

Assessment records showed that the resident had mild cognitive impairment and was completely dependent on staff for all activities of daily living. She was also always incontinent of both bowel and bladder, putting her at high risk for skin breakdown if not kept clean and dry.

Despite having an order for weekly skin checks since her admission, there was no documentation of any skin checks in her medical record. The wound care nurse later admitted that “the wound team was just treating resident’s leg wound that was present on admission and were not aware of anything going on in resident’s sacrum” until several months after admission. She acknowledged that “the wound care team did not do another skin assessment apart from the one done upon admission” and that “the facility dropped the ball this time, there was a gap in communication, resident’s wound could have been identified earlier.”

During an inspection visit, the resident was observed lying in bed and stated that she had not been changed yet that day, having been last changed the previous day, and felt that she was wet. She also mentioned that no one had changed her wound dressing yet, and she didn’t know who her assigned nursing assistant was for the day.

Later that morning, a nursing assistant and restorative aide were observed leaving the resident’s room with dirty linens. When asked to show the resident’s soiled incontinence brief, inspectors noted “a large area of reddish stain that saturated the brief.” The nursing assistant claimed the resident “was not wet, the stain is from her wounds.” When the resident’s wounds were examined, inspectors saw “a large area of deep wound on resident’s sacrum that looks red, with lots of drainage.”

Disturbingly, staff applied a clean incontinence brief on the resident with no dressing covering the wound, promising to inform the wound care nurse that the resident’s wound didn’t have any cover. Several hours later, the resident was observed still lying on her back and stated that no one had come to turn her or put a dressing on her wound.

When wound care was finally observed by inspectors, the Director of Nursing and a Wound Technician removed the resident’s incontinence brief and found it “soaked with wound drainage and there was no dressing covering resident’s wounds.” The Director of Nursing admitted “she was not aware that the resident did not have any dressing to her wounds, no one informed her.” She acknowledged that “the wound should not be left without dressing because it will be losing hemostasis” – meaning the wound would continue to drain and potentially bleed without a proper dressing.

The facility’s own policies required that residents “will be assessed to determine their risk factor(s) for pressure injury development, upon admission; weekly x 4 weeks following admission/readmission and at least quarterly thereafter” and that residents would “have their skin checked and documented utilizing the Treatment Administration Record… at a minimum of weekly.” These policies were clearly not followed in this case, leading to the development and worsening of severe pressure ulcers that ultimately required hospitalization.

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.

The Illinois Department of Health has cited and fined Breese Nursing Home when staff failed to properly assess, document, and treat a diabetic resident’s toe wound for nearly two months, resulting in bone infection that ultimately required an above-knee amputation.

The resident in question suffered from several serious health conditions—diabetes, chronic lung disease, and morbid obesity. She also received dialysis regularly due to kidney failure. Despite these challenges, the resident’s mind remained sharp and clear.

The resident’s health conditions put her at high risk for skin problems, especially pressure ulcers—wounds that form when pressure on the skin reduces blood flow to an area. Because of this risk, the nursing home had orders in place to check her skin twice weekly, during her scheduled shower days on Tuesdays and Fridays.
Summer had arrived, and the resident was going about her usual routine—dialysis treatments three times a week, meals in the dining room, and watching her favorite TV shows in between. But beneath the surface, a silent problem was developing.

One day at her dialysis appointment, the resident spoke up. “My feet hurt,” she told the dialysis nurse. The nurse took a closer look and was alarmed by what she found—a large darkened area on the resident’s left heel and a concerning red-purple area on her right great toe and the top of her right foot. The dialysis team immediately notified the nursing home about these worrisome findings.

Back at the nursing home, a nursing assistant had also noticed these changes while helping the resident shower. The assistant documented “bruising” on the resident’s right foot and a “soft spot” on her left heel, then had a nurse sign the shower sheet to acknowledge these findings. The nursing assistant later recalled that what she had documented as “bruising” was actually “two darkened areas” on the foot.

Here’s where the story takes a troubling turn. Though these skin problems were documented by the nursing assistant and reported by the dialysis center, proper treatment for both wounds didn’t begin right away. The nursing home staff promptly started treatment for the left heel—cleaning it with saline, applying betadine, and leaving it open to air—but the right toe wound was largely overlooked.

The Assistant Director of Nursing later admitted that she “was so focused on treating the resident’s left heel” that she “wasn’t aware of the area of concern on her right foot,” despite documentation showing that staff had reported it to her. Other staff members painted a picture of communication breakdowns.

Nearly two months after the initial discovery, the Certified Wound Nurse Practitioner finally examined the resident’s right foot. What she found was alarming—the resident’s second toe was ischemic, meaning it wasn’t getting enough blood flow. The tissue was dying. The wound had progressed to a dangerous state, with “abundance of purulent drainage and pain at the site.” The resident was immediately sent to the local hospital for emergency treatment.

At the hospital, the resident told doctors the wound had been present for about a month but had been getting worse and more painful. Medical imaging revealed osteomyelitis—a serious bone infection—affecting multiple toes. The infection had progressed so far that surgeons had to amputate her right second toe.

But the story doesn’t end there. Just six weeks later, the resident was back in the hospital. Her foot wound had worsened despite the toe amputation, and the infection had spread. This time, doctors determined that the only way to stop the spreading infection was to amputate her right leg above the knee—a life-altering surgery that might have been prevented with proper early intervention.

When investigators interviewed the resident after all these events, she was lying in bed with her right leg amputated above the knee and her remaining left foot in a protective boot. She told them her feet still hurt all the time, rating her pain as a 6 out of 10 in her right residual limb and 8 out of 10 in her left foot. The investigators observed that her remaining left foot showed signs of poor circulation, with darkened skin between all toes and a scabbed-over dark heel.

The nursing home’s own policy stated they were “committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries.” The policy clearly defined responsibilities: licensed nurses were to “conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury” with findings “documented in the medical record.”

The Wound Nurse Practitioner put it bluntly: “Untreated wounds have the potential for serious harm or death due to infection.” The resident’s primary care nurse practitioner expected nursing staff to notify her or the physician the same day a new skin concern was identified, stating, “Staff should be assessing the resident’s feet because she has diabetes and anything on the foot with diabetes can continue to progress into a wound.”

In the aftermath of this tragedy, the nursing home implemented numerous corrective actions—conducting skin assessments on all residents, reviewing medical records to ensure weekly assessments were completed, revising policies, and educating staff. But for the resident who lost her leg, these changes came too late.

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.

The Illinois Department Of Health has cited and fined Elevate Care South Holland when they failed to administer antibiotics to a resident when lab results indicated a bedsore infection. As a result of the failure to communicate the results to the resident’s doctor and nurses, the wound was left untreated for two weeks and progressed to a stage 4 bedsore and bone infection requiring hospitalization.

The resident in question was admitted to the facility with multiple conditions including a stage three pressure ulcer, quadriplegia (paralysis of all four limbs), and other health issues.

The incident began when a wound care specialist noted concerning changes in the resident’s pressure ulcer, including an unpleasant odor and greenish drainage. They ordered a wound culture (a test to check for bacteria) and requested an infectious disease consultation. The wound at this time measured 5 centimeters by 4 centimeters with a depth of 0.1 centimeters.

The lab results, which came back four days later, showed a serious infection: “high amount of bacteria greater than 100,000 of pseudomonas aeruginosa.”

Unfortunately, these results weren’t properly communicated to the necessary medical staff. As noted in the report: “the facility failed to follow their physician notification of laboratory/radiology/diagnostic results policy by not notifying the physician/nurse practitioner of a sacral wound culture results.”

The wound continued to worsen. An additional four days after the lab results were received it had significantly deteriorated, with the documentation showing it had grown to “8 centimeters length x 8.5 cm width x 2 cm depth” – a substantial increase in size and depth. The wound was now classified as stage 4, which is more severe than its previous stage 3 classification.

Due to the lack of communication about the lab results, the resident did not receive any antibiotic treatment. The report notes that “the resident’s medication administration record and physician orders did not document any new antibiotic treatment after the lab results were received.”

Two weeks after the culture results came back, the wound remained untreated and the resident had to be hospitalized with a diagnosis of sacral osteomyelitis (an infection in the bone).

Multiple healthcare providers interviewed stated they were unaware of the culture results. The Infectious Disease Nurse Practitioner stated “he was not aware of the resident’s wound culture results and would have ordered antibiotics for the resident.”

Another physician noted that “there should have been intervention sooner in relation to the wound culture results.” The facility’s own care plan had specifically called for staff to “monitor for signs and symptoms of infection (redness, warmth, swelling, pain, excessive drainage, odor) and notify provider.”

Unfortunately for this resident the wound monitoring and notification process at Elevate Care South Holland appears to have broken down.

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.

The Illinois Department Of Health has cited and fined La Bella Of Danville when a resident experienced recurring infestations of maggots in his leg wounds due to inadequate wound care and dressing changes.

The resident in question was admitted to the facility with multiple diagnoses including acute kidney failure, type II diabetes mellitus, morbid obesity, and various wounds. Despite being cognitively intact, the resident was dependent on staff for proper wound care.

The resident’s wounds were initially evaluated by a Wound Physician, who documented multiple large wounds on the resident’s legs and ordered a specific wound care regimen. This included the application of “0.1% Triamcinolone cream to both legs with 4-layer compression wraps from ankle to knee, twice a week.”

The first incident of maggot infestation occurred approximately five days later. The Wound Nurse reported that “a Licensed Practical Nurse notified her she found maggots in the resident’s leg dressing and in his wheel chair.” This led to a new wound care order from the Wound Physician, including washing the resident’s legs with Betadine and applying new dressings every other day for 30 days.

Despite this intervention, a second maggot infestation was discovered approximately one week later. During an examination, “the Director of Nursing (DON) removed the resident’s right lateral and medial leg wound dressings and the dressing pulled away from the wound contained 7 adult size (length of a diameter of a dime) live maggots.” The DON acknowledged the severity of the situation, stating, “this is the second time the resident has gotten maggots in the facility, as he was notified the resident had maggots in his wounds last Monday. The DON said this is unacceptable care.”

The investigation revealed that prescribed dressing changes were not being performed as ordered. A Registered Nurse had documented completing the dressing changes but later admitted, “we only had three Certified Nursing Assistants (CNAs) and the nurses were having to help pass trays and feed and I just got busy and forgot to do it after I charted it.”

The consequences of this neglect were severe. The resident’s wounds deteriorated significantly. One wound evaluation showed that the resident’s right anterior medial leg wound had increased from 8cm x 5cm to 16cm x 14cm in just six days.

The resident experienced considerable pain due to this neglect. The resident reported that “he had terrible pain in his legs and feet and behind his eye” and that “the pain in his legs had been worse recently, but he didn’t know why, and he needed someone to address it.”

The severity of the situation was acknowledged by multiple healthcare professionals. A Nurse Practitioner stated, “This has to be dealt with immediately. It could have been prevented and it could certainly have made the wound worse causing infection. This is unacceptable care.” The Wound Physician expressed concern about the frequency of dressing changes, saying “based on the size of the maggot, he questioned whether the dressings were being changed as ordered.”

This case highlights a critical failure in providing basic wound care, resulting in unnecessary suffering for the resident, potential for serious infection, and deterioration of existing wounds. It underscores the importance of adhering to prescribed care routines and maintaining adequate staffing levels to ensure proper patient 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.

The Illinois Department Of Health has cited and fined Shawnee Senior Living when staff failed to accurately assess, treat, and prevent a significant both mental and physical decline in condition for a resident. This failure resulted in the resident, who has a history of confusion with infections, experiencing altered mental status and refusing overall care after being diagnosed with a urinary tract infection. The resident’s refusals of care additionally led to the resident developing a Stage 3 pressure ulcer with sepsis secondary to skin and soft tissue infection, subsequently requiring an 11-day hospitalization for IV antibiotic therapy.

When a resident is being considered for admission to a nursing home, one of the judgments that the admissions staff must make is whether the resident has care needs which would make him unsuitable for the facility or has care needs which cannot be met at the facility. This is an especially critical judgment where a resident has a demonstrated history of psychiatric and behavioral issues which demonstrate a pattern of aggressive or threatening behaviors because a nursing home is often filled with residents who due to physical or mental infirmities may not be able to fend off an aggressor.
The nursing home administration here made a poor decision to readmit this resident and then compounded the problem by failing to train or empower the staff as their proper role in protecting residents and then failing to provide the care this mentally ill patient needed, despite the very difficult situation staff members were presented with.

The story is a troubling account on many levels. For the resident, it is a sad account of unmet psychiatric needs and neglect of physical needs at a nursing facility.

The individual was a long-term resident with a history of suffering mental confusion during infections. He was readmitted to the facility following a hospital stay for treatment of a urinary tract infection (UTI) with extended spectrum beta-lactamase (ESBL) bacteria. Upon return, the resident had orders for Augmentin 875-125 mg twice daily for 10 days to treat the UTI.
From the moment of readmission, signs of trouble were apparent. The progress note from the day of admittance noted that the resident was “alert and oriented to person, place, and time, refused a skin evaluation and was refusing to take medications as ordered.”

Over the next few days, the resident’s condition rapidly deteriorated. Just two days after readmission, a progress note at 5:11 PM documented, “referral information faxed to a behavioral hospital for possible placement related to the resident’s delusions, refusal of care, and verbal behaviors.” Another note from the same day at 3:08 PM painted a concerning picture: “Resident refused to get up out of bed. He is mumbling to himself unable to understand what he is saying. He refused to take all meds. He would not allow writer to take his vitals.”

The situation continued to worsen. On the fourth day after readmission, a progress note at 5:27 PM stated, “Resident has been in room talking to people that are not there all day he was heard telling people to get out of his room and mumbling under his breath. He refused to get up this shift has refused all meds. He did allow (blood glucose monitoring) but not insulin.”

Approximately a week after readmission, the severity of the resident’s condition was clear. A progress note at 4:13 AM documented, “refused meds and meals for past 1-2 weeks.” The next day a particularly disturbing note at 3:26 PM read, “CNA (Certified Nursing Assistant) states that resident has been incontinent of stool and is lying in his bed with genitals exposed and refusing to be changed.”

The neglect reached a critical point several days later. A progress note at 2:55 AM described a horrifying scene: “All shift resident has refused to let staff change him. Resident’s bed is saturated in urine and dripping into the floor. Resident has a puddle of urine under his bed and was trailing to the door. Resident let staff clean the urine from his bed to the door but refused to let staff change him or clean under the bed.”

Throughout this period, the resident was consistently refusing medications. The Medication Administration Record (MAR) showed that the resident refused Augmentin 16 out of 20 offered dosages. He also refused another antibiotic, Levaquin, 5 out of 7 offered doses.

The neglect culminated a day or so later when the resident became physically aggressive towards another resident. The aggressor entered the other resident’s room and attempted to pull the resident out of bed, claiming he was “shooting him with black stuff.” This incident finally prompted the facility to send the resident to the emergency room.

Upon arrival at the hospital, the full extent of the physical issues the resident had suffered became apparent. The emergency room record documented the resident as having “wounds on his bottom.” Further examination on the following day revealed the resident had developed severe pressure ulcers: a Stage 3 pressure injury on his left buttock measuring 4 cm in length, 2.5 cm in width, and 0.3 cm in depth, and a Deep Tissue Pressure Injury (DTPI) on his right buttock. The resident was diagnosed with sepsis secondary to skin and soft tissue infection.

The resident’s case highlights a systemic failure to provide appropriate care, with staff seemingly more concerned with documenting refusals than finding ways to provide necessary medical treatment and hygiene care. The facility’s approach to the resident’s declining condition could demonstrate a lack of understanding of the interplay between infections, mental status changes, and the need for persistent attempts to provide care even when a resident is initially refusing.

At the same time, when a resident is victimized in a resident-on-resident assault, it is incumbent upon the administration to determine whether that resident should remain in their facility. On this point it would seem that the administration made the correct decision in sending the resident out to the ER. Whether the resident should have been initially admitted to the facility, or sent out to the ER at an earlier date, is another question.

It could be argued that the resident was allowed to stay in the facility for too long, ultimately resulting in the resident assaulting another resident. It should have been obvious to the administration that this was not a proper resident to have in the facility in the first place. A nursing home is a “home” for many residents where they live full time. They do not deserve to be terrorized in their own home. And the resident that was assaulted was not provided with the level of protection he deserved.

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 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.

IDPH has cited and fined Paris Health & Rehab Center when a resident developed complications from a pressure ulcer on their right heel, ultimately leading to hospitalization for osteomyelitis and the discovery of maggots in the wound.

The resident in question was admitted with multiple medical conditions including type 2 diabetes, pressure ulcer on the right heel, and hemiplegia following a cerebral infarction. The resident’s care plan included interventions for daily skin checks, floating heels, and monitoring for signs of infection.

The Wound Nurse Practitioner documented the resident’s right heel wound measuring 4.1 cm x 2.5 cm x 0.1 cm and applied a skin graft with specific dressing instructions. However, subsequent notes indicate issues with dressing adherence and odor.

Approximately two weeks later the situation drastically deteriorated. The Director of Nursing documented a change in the resident’s condition, noting “increased drainage and odor” from the wound. When the Wound Nurse Practitioner examined the resident, she found the wound had “foul smell and had deteriorated.” The Nurse’s assessment revealed “Strong odor and new wound beneath dressing when removed. Increased measurements. Wound declined with unstable eschar noted within wound bed.”

Most alarmingly, when the resident was admitted to the hospital shortly thereafter, the records state that “reportedly maggots were expressed from the wound along with malodorous material.” The following day an MRI confirmed “soft tissue ulcer in the plantar subcutaneous tissues inferior to the posterior calcaneal bone associated with both cellulitis and Osteomyelitis.”

Interviews with staff members revealed a concerning lack of proper wound care and communication. Multiple staff members noticed a strong odor in the days leading up to the admission to hospital, but failed to take appropriate action.

A Licensed Practical Nurse (LPN) stated, “the shower aide told the LPN that the resident’s odor was really bad and thought she was going to throw up from the smell. The LPN stated she informed the Business Office Manager regarding the strong odor but did not document anything about it or notify the Wound Nurse Practitioner.”

The Wound Nurse Practitioner expressed concern about the lack of communication, stating, “that she was not made aware of the strong pungent smell coming from the resident’s wound and should have been made aware.”

The resident himself reported, “the wound was smelling but staff didn’t do anything except agree that it smelled.”

This incident highlights significant failures in wound care management, staff communication, and adherence to care plans. Despite the resident being identified as high-risk for pressure ulcers with specific care instructions, staff members failed to properly monitor the wound, report concerning symptoms, or take timely action when issues were noticed. These lapses in care resulted in a severe decline in the resident’s condition, necessitating hospitalization and long-term antibiotic treatment for osteomyelitis.

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.

IDPH has cited and fined Bethany Rehab nursing home after a resident there died due to a bed sore that went largely untreated in the nursing home and became infected due to poor care.

“Bed sores” are the commonly used term for pressure ulcers, which are breakdowns in the skin which can lead to infections and other serious negative health consequences.  There are specific federal regulations which address the development and care of bed sores, so they are a source of intense focus in the long-term care industry.

There are a number of factors which place a resident at risk for developing bed sores.  The most common are immobility, incontinence, and poor nutritional status.  There are other factors as well, and these are wrapped into an assessment tool known as the Braden Scale, which measures the resident’s risk of developing bed sores.

When the resident was admitted to the nursing home, she was coming directly from a local hospital.  The discharge summary from the hospital included, amongst other ailments, a “sacral suspected deep tissue injury hospital acquired, (adhesive foam dressing) sacrum dressing changed every 3 days and as needed.” 

Unfortunately for the resident, the admission assessment at the nursing home indicated that the new resident did not in fact have any impairment in skin integrity.  This was in direct contrast to the discharge summary from the hospital.

Two weeks later, a nursing note continued to acknowledge the hospital acquired sacral deep tissue injury.  The nursing note indicated that the resident had “no new issues” regarding her skin integrity. 

It was only approximately 5 weeks after the date of admission that a nursing note indicated “wound care provided to sacral area.” 

Every weekly skin assessment, from the date of admission, made no mention of the sacral deep tissue injury that was acquired in the hospital prior to admission. 

A few days after the first mention of the wound in a nursing note, a new note indicated that “resident found with eye open nonverbal but will track you with eyes, wound on coccyx bleeding now, dressing applied, 911 ambulance took resident to (local emergency room) for eval.”

The report from the emergency room states that there was a “quarter sized circular opening mid lower sacrum/coccyx draining serosanguinous fluid. Skin over the lower back is warm, hot, erythematous, and tender. Able to express fluid with palpation. Foul smelling drainage.”

Unfortunately, the resident was operated upon, suffered cardiac arrest, and passed away several days later.  The resident’s Death Certificate showed cause of death as sepsis, gluteal abscess necrotizing fasciitis and atrial fibrillation.

There are a couple of significant failures in the care of this resident which led to her death:

1.  There was an initial failure to document the bed sore that was clearly mentioned in the discharge summary from the local hospital.  If the admission assessment had acknowledged the wound, steps could have been taken to address the bed sore at an early stage.

2. Despite the existence of the hospital acquired bed sore, there was a delay in excess of five weeks before the nurses notes mention any treatment of the bed sore.  

There are likely other failures.  The sad fact about bed sores is that these are injuries which do not occur in a flash moment of time such as with a nursing home fall or a choking accident.  Rather these were failures that spread across multiple days, multiple shifts, multiple staff members.

These systemic failures are often a sign of an understaffed nursing home.  Sadly, that is a basic part of the nursing home business model.  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.

IDPH has cited and fined Victorian Village Health & Wellness nursing home in Homer Glen after a resident there developed a pressure ulcer on her heel from her orthotic boot.

“Pressure ulcers” are commonly referred to as bed sores because they frequently develop on persons who are unable to get out of bed and are caused by pressure from the weight of the body against the bony prominences.  This is why some of the most common parts of the body for bed sores to develop are the buttocks, hips, sacrum, and heels.

However, pressure from the weight of the body is not the only way that pressure ulcers can develop.  One common way for bed sores to develop is pressure against the body from medical devices and equipment such as casts, catheters, immobilizers.  The risk associated with the use of these devices is well-known in long-term care industry and should be addressed in the care planning process.  The risk from these devices can be mitigated by frequent skin inspections; checking the device for fit, condition, and positioning; and obtaining doctor orders permitting removal when appropriate.

The resident at issue was admitted to the nursing home for rehabilitation after suffering a fall at home.  One of the complications that she had as a result of the surgery was that she had a drop foot on one side for which she was given an orthotic boot to wear.  On admission to the nursing home, she underwent a full skin inspection and there were no pressure ulcers.

After being admitted to the nursing home, she would periodically complain of a burning sensation in the heel.  However, no one would take the boot off to inspect the underlying skin or the condition of the boot; they would simply loosen  the boot for a period of time.  Further, no one notified the doctor that the resident was complaining of a burning sensation in the heel.

The pressure ulcer was not discovered until the resident had been admitted to the nursing home for about 10 days, at which point a staff member removed it to clean the foot.  At this point, the wound was considered an unstageable pressure ulcer which is by definition at least a Stage 3 or possibly a Stage 4 pressure ulcer.  According to the citation, the wound had extended up to the Achilles tendon of the resident.

Why did the resident develop the pressure ulcer?  Inspection of the boot revealed that even though it was lined, a portion of the lining had worn away so that the heel of the resident was laying directly on the frame of the boot.  This is exactly the kind of thing that causes pressure ulcers to develop with the use of medical devices and equipment – prolonged pressure from an inadequately padded device.

What should the nursing home have done?  For starters, the regular inspections of the skin and the device were not done.  Had the boot been removed and the condition of the skin and the boot been observed, the relationship between the resident’s complaints about a burning sensation in her heel would have been readily apparent.  Beyond that, the frequent appearance of a burning sensation in the heel also should have resulted in physician notification.  This was not done.

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.  Order our FREE report, Built to Fail, to learn more about why.  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.

Other blog posts of interest:

Moweaqua Rehab resident develops pressure ulcer from fracture brace

Resident at Christian Nursing Home in Lincoln develops pressure ulcer from brace

Oak Brook Care Center resident develops pressure ulcer from immobilizer

Pressure ulcer from surgical boot at Amberwood Care Center

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

In a tragic case, the IDPH has issued a citation to Bridge Care Suites in Springfield, IL, after one of its residents died from an infected bedsore. 

What was supposed to be a short stay turned into an agonizing and ultimately fatal battle for the resident. 

From Post-Injury Rehab to Fatal Infection

The resident had broken her hip in a fall and was admitted into Bridge Care for short-term rehabilitation. At the time of her admission, she already had a small bedsore on her tailbone, about 3×4 centimeters.

When a resident comes to a nursing home with a bedsore, the standard practice is for the facility’s staff to contact the doctor for treatment orders. This was not done, because staff were instructed to only call the doctor if the bedsore was Stage 3 or higher. The fact that they didn’t reach out to a doctor upon the resident’s admission indicates that her bedsore was only Stage 1 or 2.

Within 19 days of her stay, the resident’s bedsore grew to the stage 3 category. At this point, her care plan only included the use of a pressure-relieving cushion on her wheelchair and no other intervention for bedsore. Her wound had worsened, but nobody obtained additional treatment orders from the doctor.

The resident then visited a wound care clinic. There, a nurse practitioner saw that the resident’s wound was not properly dressed and that she was not on a pressure-relieving wheelchair cushion.

In the NP’s account to the state surveyor, she was mortified by the resident’s condition, particularly to the “nasty” wound that already had a foul smell. It had also grown in size, had dead tissue on the wound bed, and was tunneling underneath such that bone was palpable. The NP debrided the wound, which was now classified as a Stage 4 bedsore.

Unfortunately, the nursing home still did not update the resident’s care plan despite the progression of the wound. Within four days of her return to the home, she began to suffer significant pain at her coccyx (tailbone), a common sign of osteomyelitis or bone infection.

Again, despite the new complaints, there was no call made to the doctor. The resident’s pain increased, and she now also had nausea and changes in mental status.

Meanwhile, her son had grown concerned and called the nursing home. He had to wait for a callback from the nurse’s station, at which point they asked him what he wanted to do.

Paramedics arrived at the nursing home and transported the resident to the ER. On arrival, she was already struggling to breathe and had no pulse or blood pressure. She was pronounced deceased within an hour. The pathologist certified her cause of death as sepsis and decubitus ulcer, and also found neglect in the case.

Multiple Failures in Resident’s Care

There were multiple failures in caring for this resident, which started at the moment of her admission when the staff did not notify the doctor about the bedsores. Her care plan was thus inadequate.

Second, her care plan was not revised as her wound worsened. Updating the care plan is a fundamental step in the care planning process. Nursing homes have the responsibility to look out for progressing medical issues in any of their residents and to reach out to a physician so that the resident’s care plan can be revised accordingly.

Bedsores are a particularly crucial issue because they are so common and can easily lead to serious medical conditions. The US has specific federal regulations mandating nursing homes to provide care to prevent sore infection, promote its healing, and prevent additional bedsores. 

The deceased resident’s bedsore should have been taken seriously.

Further, her additional complaints of increasing pain should have prompted immediate medical action. Yet the physician was not called even at this point.

In an interview with the state surveyor, the wound care nurse at the facility said that when he began there, they did not have a wound care nurse in place. As he took on the role, he only got minimal training and almost no supervision. He did not even know of any policy or procedure to guide him in the provision of care. 

These comments indicate serious shortcomings in facility management, involving poorly trained, unqualified, or inadequate staff.

This substandard condition sadly led to the demise of an individual — a very preventable death. A nursing home can take steps to prevent or heal bedsores and thus protect their residents from life-threatening infections — if only the facility is serious and competent in fulfilling their duties.

Contact an Illinois Nursing Home Lawyer for Legal Help

We believe that most 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 results. 

Order our FREE report, Built to Fail, to learn more about why. 

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.

Click here to file a complaint about a nursing home with the Illinois Department of Public Health. 

Thank you for reading.

 

Other blog posts that might be of interest:

Rushville Nurisng & Rehab resident suffers untreated surgical wound infection

Lexington Of Orland Park Resident Suffers Stage 4 Bed Sore

Sharon Health Care Willows Resident Undergoes Surgery For Bed Sore

Stephenson Nursing Center Resident Undergoes Surgery For Bed Sore