Inspectors: Two aides reported the man’s wound looked like ‘hamburger’
A hospital-affiliated nursing home in northwest Iowa has been cited for contributing to the death of a resident.
State and federal records show that in January, the staff at Sanford Senior Care in Sheldon, which is a 70-bed nursing home affiliated with the Sanford Medical Center, found that a male resident of the home had developed a reddened area on his coccyx. The staff failed to assess and treat the situation or notify the man’s family or physician — even after it developed into an open sore in February, according to inspectors.
A nurse aide later told state inspectors that she informed a nurse on March 4 that the area around the wound “looked like hamburger” and there was blood seeping through the white cream the staff had applied to the wound. The aide reported her observations to a nurse, who later acknowledged to inspectors that she had received the information but was too busy to check the wound herself.
On March 6, the resident was admitted to the hospital’s emergency room with a Stage 4 wound, indicating there was sufficient loss of tissue to result in exposed bone, muscles or tendons, with the potential for a serious complication such as an infection.
The resident died two days later. According to state inspectors, the immediate cause of death was MRSA cellulitis — a dangerous skin infection that stems from staph bacteria — caused by the open wound.
A second nurse aide interviewed by inspectors allegedly reported that the last time she examined the man’s wound “it looked absolutely awful,” and the resident’s overall color was “off” and he appeared gray and purple. “There was bloody skin on both sides of the buttocks and continuing down it looked like hamburger,” the aide reportedly told inspectors.
The facility’s director of nursing allegedly informed inspectors that certain employees were disciplined as a result of the death, adding, “We are trying to do everything possible to prevent this from occurring again.”
Administrator Richard Nordahl referred all questions on the matter to Sanford Health. A spokesperson for the company indicated Tuesday that he was unable to comment on the matter at that time.
No state fines were imposed as a result of the death. Federal records indicate the Centers for Medicare and Medicaid Services imposed a civil money penalty of some kind, but a CMS spokesperson was unable to say Tuesday what that fine totaled.
CMS’ Care Compare website, which provides information for consumers that is often out of date, indicates Sanford Senior Care in Sheldon has been fined twice in the past three years, most recently in 2024 when it was fined $11,872.
On CMS’ five-star quality scale, the Sheldon facility currently has a one-star overall rating — the lowest possible score.
