SAVANNAH, GA - A federal inspection has revealed serious safety violations at Oaks Health Center at the Marshes of Skidaway Island after a hospice patient sustained bilateral femoral fractures and a right humeral fracture when she rolled out of bed during routine care.
Severe Fall Results in Multiple Fractures
The incident occurred on December 16, 2024, at approximately 6:19 am when a Certified Nursing Assistant (CNA) was providing care to Resident 115, who required two-person assistance for all activities of daily living according to her care assessment. The resident, who was under hospice care and had severe cognitive impairment with a mental status score of 5 out of 15, was being assisted by a single aide when the fall occurred.
According to the fall incident report, the CNA was changing the resident's bed linens when "she rolled out of bed and hit her head on the floor." The aide stated she was unable to catch the resident, who "rolled off the bed onto the floor." The resident sustained a hematoma to the right side of her head and a skin tear to her lower right extremity, both of which were bleeding.
Emergency Medical Services transported the resident to the hospital at 7:25 am. Hospital records confirmed the resident had sustained bilateral femoral fractures and a right humeral fracture. Due to the high surgical risk and the resident's hospice status, the family and medical team decided against surgical repair of the fractures.
Two-Person Care Requirement Ignored
Federal inspection records show the resident's most recent quarterly assessment documented that she required two-person assistance for all self-care and mobility activities, with staff performing "all of the effort" while "the resident does none of the effort to complete the activity."
During interviews, CNA BB confirmed she had changed the resident before by herself, despite the documented care requirements. The aide explained that during the incident, she "instructed [the resident] to turn on her side and hold on to the bed rail" while she changed the fitted sheet. When the resident "began moving forward," the aide "tried to catch her from falling, but she slipped out of her hands and fell."
The CNA also noted that the resident "seemed to have increased confusion on that day and tried getting out of bed multiple times during her shift," indicating heightened fall risk that should have prompted additional safety measures.
Licensed Nurse Offered Additional Help
A Licensed Practical Nurse working the same shift revealed she had observed the resident's legs hanging out of bed earlier and asked the CNA if help was needed. The LPN stated the aide declined assistance, saying "she had changed her by herself" previously.
When called to respond to the fall, the LPN found "the resident on the floor in a sitting position with a pool of blood on the floor and a small hematoma on her head." The nurse applied pressure to control bleeding and contacted emergency services. The hospice nurse recommended emergency room evaluation after being notified of the incident.
Medical Implications of Fall Prevention Failures
Falls in nursing home residents with severe cognitive impairment and mobility limitations carry significant risk for serious injury. Bilateral femoral fractures, which involve breaks in both thigh bones, are particularly devastating injuries that can lead to permanent disability, chronic pain, and increased mortality risk, especially in elderly patients with multiple health conditions.
When residents require two-person assistance, this designation is based on comprehensive assessment of their cognitive ability, muscle strength, balance, and cooperation level. Single-person care for these residents violates established safety protocols and dramatically increases fall risk. Proper two-person transfers involve one person supporting the resident while the second person manages equipment and provides additional stability.
The resident's underlying conditions, including post-polio syndrome, muscle weakness, contractures in both feet, and abnormal gait, made her particularly vulnerable to serious injury from any fall. Her severe cognitive impairment score of 5 out of 15 indicated she likely could not follow instructions or assist with positioning, making appropriate staffing levels critical for safety.
Additional Safety and Care Violations
Federal inspectors also identified medication safety violations during the same inspection. A registered nurse administered celecoxib 200mg to a different resident based on a physician's order that failed to specify the dosage. The order simply stated "celecoxib one capsule by mouth one time a day" without indicating the strength.
The Assistant Director of Nursing confirmed the order was not transcribed accurately and should have specified a dosage. This type of medication error can lead to under-dosing or over-dosing, potentially causing inadequate pain relief or serious side effects including cardiovascular and gastrointestinal complications.
Infection Control Deficiencies
Inspectors documented multiple infection control violations during wound care procedures. A registered nurse treating a resident with a stage four pressure ulcer failed to establish a clean work surface and did not perform hand hygiene between contaminated and clean procedures during wound care.
The nurse placed wound care supplies directly on an uncleaned bedside table without disinfection or barrier protection. During the procedure, she applied medication directly to the wound with her finger without changing gloves or sanitizing hands after handling contaminated materials.
Additional infection control issues were identified in the laundry area, where clean housekeeping items were stored in the soiled laundry room. This practice creates cross-contamination risks that can spread infections throughout the facility.
Industry Standards and Best Practices
Federal nursing home regulations require facilities to ensure residents receive care consistent with professional standards of quality and maintain environments free from accident hazards. When residents require two-person assistance, facilities must ensure adequate staffing and supervision to prevent falls and injuries.
Proper fall prevention protocols for high-risk residents include environmental modifications, appropriate staffing ratios, and careful assessment of each resident's specific needs and limitations. Staff should never attempt care procedures that exceed safe staffing guidelines, particularly for residents with cognitive impairment who cannot assist with their own safety.
Facility Response and Oversight
The facility's Director of Nursing confirmed during interviews that nursing staff are responsible for transcribing physician orders and that consulting pharmacists review orders monthly. However, the medication dosage error had not been caught despite these review processes.
Regarding the fall incident, the Medical Director noted that the resident had experienced a previous fall approximately 18 months earlier and had multiple comorbid conditions including osteoporosis, which increased her fracture risk. The resident passed away on January 31, 2025, with atherosclerotic heart disease listed as the immediate cause of death on her death certificate.
The inspection findings demonstrate systemic issues with safety protocols, medication management, and infection control practices at the 95 Skidaway Island Park Road facility. Federal regulations require nursing homes to correct identified deficiencies and implement measures to prevent recurrence of violations that place residents at risk of harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oaks Health Ctr At the Marshes of Skidaway Island from 2025-01-19 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.