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.
