An elderly gentleman that lived in a nursing home began complaining of pain in his leg. The family noticed his foot was warm and notified the nursing home staff. Although the nursing home records document the doctor was called, she never came to evaluate the leg. The doctor testified her office never received the call. Over the next two weeks the nursing home documented red streaks running from the foot to the knee, increasing pain in the foot and leg, and black rotting skin on the toes. Although he was finally sent to the hospital, it was not in time. The man was severely dehydrated and the lack of blood flow to the foot had caused severe gangrene. His leg was amputated and he died from the stress about a month later. Nursing staff testified the facility was understaffed, they did not have time to provide quality care to the residents, they had complained to management about the situation, and management had refused to increase staffing. The nursing home claimed that providing care earlier would not have made a difference to the man’s outcome.