A 71-year-old male resident at a Residential Care Facility for the Elderly (“RCFE”) was not discharged despite the fact that he had a Stage III pressure ulcer on his foot. Under California state regulations, this is a prohibited condition at an RCFE and the facility was required to discharge him to a facility that could provide medical care necessary for the wound. The facility chose to keep him as a resident despite the worsening wound. The wound became infected. By the time the resident was released to the Emergency Department, it was too late for his lower extremity which was amputated below the knee. Case settled for $450,000.