Francis Stevens, 58, was admitted to Garden Spring Nursing & Rehabilitation Center. At the time of his admission, he suffered from rheumatoid arthritis, heart failure and venous insufficiency.
Stevens was also at high risk for pressure ulcers. Several months after his admission, he developed foot wounds and experienced weight loss. Abnormal lab results and a change in his condition prompted his transfer to a hospital, where he was diagnosed with sepsis and chronic lower extremity wounds.
Stevens was discharged from the hospital with instructions for daily wound care and skin breakdown prevention. However, Stevens was hospitalized several more times over the next five months, including for treatment of multiple pressure sores on his heel, sacrum and knees.
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