SANDALWOOD HEALTHCARE, LLC
LOCATED: 2600 JOHN BARROW ROAD, LITTLE ROCK, AR 72204
SANDALWOOD HEALTHCARE, LLC was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO GIVE RESIDENTS PROPER TREATMENT TO PREVENT NEW BED (PRESSURE) SORES OR HEAL EXISTING BED SORES.
LEVEL OF HARM –IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Complaint # (AR 408) was substantiated (all or in part) with these findings.
Based on observation, record review and interview, the facility failed to consistently assess, monitor and document the condition of pressure ulcers for 2 (Residents #1 and #3) of 4 (Residents #1, #2, #3 and #5) case mix residents who had pressure ulcers. The facility failed to relieve pressure to an existing pressure ulcer and failed to obtain a new treatment order when the wound did not improve for 1 (Resident #3) of 4 (Residents #1, #2, #3 and #5) case mix residents who had pressure ulcers. The facility failed to notify the physician of signs of wound infection for 1 (Resident #1) of 4 (Residents #1, #2, #3 and #5) case mix residents who had pressure ulcers.
These failures resulted in immediate jeopardy which caused or could have caused serious harm, injury or death to Residents #1 who had pressure ulcers that subsequently led to the resident being hospitalized and expiring due wound [MEDICAL CONDITION] and to #3 who had a recurrent pressure sore that deteriorated from stage II to unstageable. These failures had the potential to cause more than minimal harm for 5 residents who had pressure ulcers according to a list provided by the Administrator on [DATE] at 1:32 p.m. The facility was informed of the immediate jeopardy on [DATE] at 11:00 a.m.
Hospital ED Note dated [DATE] documented, Wounds uncovered and assessed by MD. Unstageable wounds noted to bilat (bilateral) LE (lower extremities) and buttocks. Draining noted and foul odor present. Physical Exam: Multiple decubiti of the lower extremities and buttocks/sacral area. Assessment/Plan: Pt with multiple severe decubiti, she is septic and she also has UTI. A Hospital Progress Note dated [DATE] documented, Consult received, pt with multiple severe decubiti, gangrene of limbs. Has PEG (percutaneous endoscopic gastrostomy tube). Pt has massive wounds to hips and connecting to sacrum with black eschar. Some small areas open with foul drainage. Bilat LE with multiple arterial wounds and gangrenous and to heels and plantar foot.
On [DATE] at 10:36 a.m., the resident’s daughter was asked when the resident expired. She stated her mother was discharged from the hospital on [DATE] to Hospice and died a couple of hours later on [DATE] due to wound [MEDICAL CONDITION].
Personal Note from NHA-Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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