In August 1996, an Inverness nursing home accepted a new female patient. The medical staff noted that the resident's right big toe, which had a small cut, was red and causing pain.
Almost two months later, the wound was so close to becoming gangrenous that a surgeon was forced to amputate the woman's right leg above the knee.
Officials at the nursing home, Citrus Health and Rehabilitation Center, say the woman's medical condition was poor and that the operation was necessary despite the staff's attentive work. The home's sole slip, if any, was failing to document the good care that medical professionals provided, they say.
The state Agency for Health Care Administration appears to have reached a different conclusion. The problem wasn't just paperwork, investigators said. They found that the nursing home engaged in "poor care and treatment" that led to the amputation.
These divergent views emerged in documents and interviews that the Citrus Times has gathered during recent weeks. Although the dispute arose in 1996, the state didn't receive a complaint until recently and didn't complete its investigation until this month.
The nursing home could have faced state fines for "failing to provide services that meet professional standards of quality," documents showed.
AHCA officials held back after the home submitted, and followed, a corrective action plan that calls for additional staff training and patient monitoring.
The state still is investigating whether disciplinary action against any health professionals involved in the case would be warranted, an AHCA spokesman said Friday.
Meanwhile, the battle of interpretations goes on.
"The facility was cited for lack of documentation; however, the outcome to the resident occurred in spite of interventions by the physician and the facility," nursing home official Gary Vandenberg wrote in a statement that his office faxed to the Times last week.
Cindy A. Jones, a registered nurse specialist with AHCA, did some writing of her own _ a two-page report summarizing the investigation she conducted with another AHCA official.
"Allegation: Poor care and treatment of resident resulting in amputation of leg," Jones wrote. "Findings: Confirmed."
The Agency for Health Care Administration inspects skilled nursing facilities, more commonly known as nursing homes, at least annually. Inspectors check for compliance with state laws and codes and also inspect on behalf of the federal government, which administers the Medicare and Medicaid programs.
When complaints arise, AHCA also conducts special investigations. That's what happened when the complaint registered as CCR 000884 was filed in late 1997 or early 1998.
The source, like the patient's name and medical details, are considered private under state law. But many of AHCA's records are public.
According to those records, a two-member investigative team arrived in Inverness on Jan. 6 to check the case. Those investigators reviewed medical charts and other documents at the nursing home and Citrus Memorial Hospital, where the amputation took place.
According to the reports, here's what happened:
The home admitted the resident Aug. 28. She had a 1-centimeter open area on her right big toe. It is unclear why she was at the home, although Vandenberg, the nursing home official, wrote that the woman suffered from the open wound "and also a condition which threatened loss of both lower limbs."
He did not elaborate.
On Sept. 3, the state records showed, a podiatry consult was ordered, as well as other treatments. Four days later, a podiatrist whose name was not listed in the report evaluated the resident and ordered an X-ray and another test.
Two days later, Sept. 9, the antibiotic Cipro was ordered for 10 days.
On Sept. 16, the records said, medical staffers noted that the wound had grown and was "green . . . with drainage." Six days later, the chart indicated that the entire toe was red and that the open area was turning black.
"There has been no mention of notifying the physician of these changes in the condition of the resident's wound by the nursing staff," wrote Jones, the AHCA nurse specialist who reviewed the woman's medical records.
The records did show that the resident continued to complain about pain, Jones wrote. Medication and wound care continued to be provided.
On Sept. 25, the staff noted that the toe became "more reddened and necrotic." The latter word means "localized death of living tissue."
"The physician was contacted and no resolution was documented in the nurses' notes," Jones wrote.
Jones' report does not say what the nurses' charts showed for the next days. On Oct. 14, however, a surgeon examined the patient and recommended amputation.
Four days later, that's what happened. The resident never returned to the home.
or poor care?
AHCA officials immediately issued a citation and noted that if the home failed to submit and follow a proper corrective action plan, it could be fined as much as $3,000 per day.
It never came to that. On Feb. 13, home administrator Sandra Kelly filed a response that included a corrective action plan heavy on staff training and extra documentation, the records showed.
Cora Kurtz is program administrator for the division of health quality assurance in AHCA's Gainesville office. She said the complaint was somewhat unusual for a nursing home in Citrus County. She also noted that the Citrus Health and Rehabilitation Center, a 111-bed facility in the Highland Medical Office Complex off Highland Boulevard, has passed inspections during its four-year tenure.
Kurtz declined to comment further on the case or on the nursing home's interpretation of the citation, a copy of which the Times faxed to her.
During an interview Friday, an AHCA spokesman in Tallahassee said the agency's investigation was hampered somewhat because so much time had elapsed. He also declined to comment on the difference between the home's interpretation of events and the investigator's version.
According to nursing home officials, this incident was unfortunate but does not reflect poorly on the home's performance.
"The resident in question had received a full range of professional nursing care," wrote Vandenberg, the nursing home official.
The center is owned by the Long Term Care Foundation of Charleston, S.C., and operated by Diversified Health Services in Atlanta, a division of ServiceMaster.
The same ownership and operation agreement applies to Highland Terrace, a 48-bed assisted living facility in the same medical park.
"It was documented that during a 30-day period, there were a total of eight physician contacts from three different specialists," Vandenberg wrote. "It is documented that there was constant nursing care and that a set of standard protocols were followed. It is documented that there were physician lab orders and lab results indicating medical interventions."
The problem, if any, was paperwork.
"The concern of their visit was the documentation of the resident during the resident's stay at the facility," Vandenberg wrote. "The confirmed citation does not mention any specific professional standard of quality which was not met, nor does it outline the professional criteria for which the facility was held responsible."