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.
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