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Client develops gangrene on his right foot resulting in amputation

Nature of Visit:

The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type.


It is alleged: The facility neglected the client when staff failed to assess and report a change in the client's condition when the client developed gangrene in his right foot. The client was sent to the hospital and underwent surgery for amputation of his right foot. As a result of the gangrene, the client eventually had a below the knee amputation (BKA).

Investigative Findings and Conclusion:

Neglect was substantiated. The facility was responsible for the maltreatment. The facility neglected the client when staff failed to monitor the client's skin and provide daily scheduled foot checks until he had blackened toes. The client developed gangrene on his right foot, which required amputation.

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