IDPH has cited and fined Arcadia Care Auburn when the facility failed to schedule a vascular consultation promptly, resulting in a deterioration of the resident’s condition and a delay in critical medical interventions.
The resident in question was admitted to the facility with a history of end-stage renal disease, peripheral vascular disease (PVD), and other comorbidities. Upon admission, the resident’s left great toenail was missing with an open wound, and her legs were edematous.
The Wound Physician noted that the resident’s feet were cool to touch, had moderate edema, and dark discoloration of the toes. The resident complained of 8/10 pain in both feet/toes. The Wound Physician recommended an ankle-brachial index (ABI) test and a vascular consult “if considered appropriate by med director/primary.”
Two days later an ABI was ordered by the physician due to pain and cool feet/toes. A week after the test was ordered, a Podiatrist assessed the resident and noted that her left foot was “ice cold from the distal digits to the ankle,” with absent hair growth and cyanosis bilaterally. The Podiatrist noted that “the entire hallux left foot is showing lines of demarcation for gangrenous changes” and requested a vascular consultation.
A little over a week later the resident’s Physician/Medical Director noted progressive worsening of PVD and significant pain in her lower extremities, increasing her pain medication. The Physician referred the resident to vascular surgery for further evaluation and three days later the ABI results confirmed claudication, a symptom of PVD.
A Nurse Practitioner noted the resident’s continued decline and recommended a referral to vascular surgery or hospice for better pain control. The same day an RN documented that the resident’s left great toe was “mottled, black-necrotic, hard, cold” and right 2-4th toes were “mottled, black-necrotic, hard, and cold.” Over the following days, the resident was constantly screaming out in pain, and her pain medications were not effectively controlling her symptoms.
A full three weeks after the first diagnosis, an RN ordered a vascular consultation for the resident’s bilateral toes. The Wound Physician also recommended a vascular consult or hospice care with aggressive pain control. However, the vascular appointment had not been scheduled by the time the resident was transferred to the hospital, a full 3 and ½ weeks after the initial consult.
At the hospital, the resident was diagnosed with septic shock and bilateral lower extremity gangrene. The Emergency Physician noted that “her legs are no longer salvageable and there are no revascularization options for her at this time. She would need bilateral lower extremity amputations. She is quite sick and unstable at this time.” Unfortunately the resident passed away the following day.
Facility staff acknowledged that the resident’s vascular consultation should have been scheduled more promptly. The Nurse Practitioner stated, “I expected the vascular consult to be done timelier,” while the resident’s Physician said, “facility should have gotten her into see vascular doctor sooner.”
The facility failed to document discussions with the resident’s family regarding her condition and prognosis, despite her deteriorating state and the need for critical decision-making.
Unfortunately, the facility had multiple shortcomings:
1. Significant delay in providing timely vascular consultation and treatment.
Despite recommendations from multiple healthcare professionals, the facility failed to schedule a vascular consultation promptly, resulting in a deterioration of the resident’s condition and a delay in critical medical interventions.
2. Inadequate pain management and symptom control.
The resident experienced severe, uncontrolled pain that was not effectively managed by her prescribed medications, leading to constant screaming and suffering.
3. Insufficient communication and decision-making with the family.
The facility did not adequately communicate with the resident’s family regarding her condition, prognosis, and treatment options, particularly concerning her declining health and the potential need for hospice care.
4. Inconsistent monitoring, reporting, and care coordination.
There were inconsistencies in staff reporting of the resident’s condition, as well as a lack of clarity on decision-making processes regarding her care, suggesting inadequate monitoring and care coordination among healthcare professionals.
5. Non-adherence to facility policies and best practices.
The facility did not follow its own change of condition policy, which required consulting with the doctor and family for any changes in a resident’s condition. Additionally, there was a potential delay in recognizing and addressing the severity of the resident’s condition, leading to a late transfer to the hospital.
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 such as this one 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.
