SAVANNAH, GA - A hospice patient at Oaks Health Center at the Marshes of Skidaway Island sustained bilateral femoral fractures and a head injury when she fell from her bed during a routine linen change, according to a federal inspection report that revealed the certified nursing assistant was working alone despite the resident requiring two-person assistance for all care activities.
The December 16, 2024 incident occurred when a certified nursing assistant attempted to change bed linens for a resident with severe cognitive impairment and multiple mobility issues. The patient, who had been admitted to hospice care in October, fell head-first onto the floor, sustaining fractures to both femurs and her right humerus along with a head hematoma and skin tear.
Critical Safety Protocol Violations
Federal inspectors found that the facility failed to follow established safety protocols for residents requiring assisted care. The resident's most recent assessment documented that she was completely dependent on staff for self-care and mobility, requiring two-person assistance for all activities of daily living.
The assessment specifically noted that "the helper does all of the effort" and "the resident does none of the effort to complete the activity," indicating complete dependency on staff assistance. Despite this clear requirement, the certified nursing assistant was performing bed linen changes alone.
During the incident, the aide instructed the cognitively impaired resident to "turn on her side and hold on to the bed rail" while she changed the fitted sheet. The resident began moving forward and fell despite the aide's attempt to catch her.
Medical Complexity Increased Fall Risk
The resident's medical history significantly increased her fall risk. She had been diagnosed with post-polio syndrome, cognitive impairment, abnormal gait and mobility, contractures in both feet, and muscle weakness. Her cognitive assessment revealed severe impairment with a score indicating she could not reliably follow instructions.
Bilateral femoral fractures represent serious injuries that can be life-threatening, particularly for elderly patients with multiple comorbidities. The femur is the body's strongest bone, and breaking both simultaneously typically requires significant force or occurs in patients with severely weakened bone structure from conditions like osteoporosis.
The facility's medical director confirmed that the resident also had osteoporosis, a condition that weakens bones and increases fracture risk. Due to the high surgical risks, the medical team and family decided against surgical repair of the fractures.
Infection Control Failures Compound Safety Issues
The inspection also revealed significant infection control violations during wound care procedures. Inspectors observed a registered nurse treating a stage 4 pressure ulcer without following proper sterile technique protocols.
The nurse failed to establish a clean field for wound care supplies, placing them directly on an unsterilized bedside table. During the treatment, she applied medication directly to the wound with her finger without changing gloves or sanitizing her hands after cleaning the contaminated wound area.
Proper wound care protocols require: - Establishing a sterile field with barriers - Hand hygiene before and after resident contact - Glove changes when moving from contaminated to clean areas - Sterile technique when applying medications to open wounds
Stage 4 pressure ulcers extend through the skin and subcutaneous tissue into muscle, tendon, or bone. These deep wounds are highly susceptible to infection, which can lead to sepsis and life-threatening complications. Improper wound care technique significantly increases infection risk.
Medication Safety Concerns
Inspectors identified a medication administration error where nursing staff administered celecoxib 200mg based on an incomplete physician order that specified only "one capsule by mouth one time a day" without indicating the dosage strength. The nurse administered the medication without clarifying the intended dose with the prescribing physician.
Celecoxib is a nonsteroidal anti-inflammatory drug used for pain management. Different dosage strengths are available, and administering the wrong dose can cause side effects or inadequate pain relief. Standard medical practice requires clarification of incomplete orders before administration.
Laundry Cross-Contamination Risks
The facility also failed to maintain proper separation between clean and contaminated laundry items. Inspectors found housekeeping cleaning towels stored in plastic bags placed on top of laundry detergent containers in the soiled laundry area.
This practice violates infection control standards that require strict separation of clean and contaminated items to prevent cross-contamination. Clean items stored in contaminated areas must be re-laundered before use, as they may harbor harmful microorganisms that could spread infections throughout the facility.
Regulatory Standards and Enforcement
Federal nursing home regulations require facilities to maintain environments free from accident hazards and provide adequate supervision to prevent injuries. Facilities must ensure that residents receive care consistent with their assessed needs and capabilities.
The Centers for Medicare & Medicaid Services categorized the fall incident as causing "actual harm" to the resident, indicating that the safety protocol failure resulted in measurable injury. The medication and infection control violations were classified as having "minimal harm or potential for actual harm."
Facility Response and Outcomes
The resident was transported to the hospital via emergency medical services following the fall. Due to her hospice status and the surgical risks associated with her multiple medical conditions, the fractures were not surgically repaired. She passed away approximately six weeks later, with the death certificate listing atherosclerotic heart disease as the cause of death.
The facility's Director of Nursing acknowledged during interviews that proper protocols require two-person assistance for residents with the documented care needs and that infection control procedures were not followed during the observed wound care.
Oaks Health Center at the Marshes of Skidaway Island must submit a plan of correction to address the identified deficiencies and demonstrate how they will prevent similar incidents from occurring. Federal oversight will continue until inspectors verify that proper safety protocols have been implemented and maintained.
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.
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