The March 26 incident at Accel at College Station triggered an immediate jeopardy citation from federal inspectors, who found that CNA A knowingly violated the facility's care plan by working alone with a resident whose medical conditions required constant two-person assistance.
The resident, who weighed more than 260 pounds and had Class III obesity, was admitted with congestive heart failure and varicose veins. Her care plan, revised in November 2021, specifically required two staff members for all activities of daily living including toileting, transfers, bed mobility, and bathing.
CNA A told investigators she "felt like the facility was short staffed and she did not want to bother the other staff and ask for help." She admitted she had helped the resident alone previously, even though she knew the resident required two-person assistance.
The incident occurred when CNA A was giving the resident a bed bath. According to her unsigned statement, "when I turned her over to clean the other side of her, she slid out of her bed on to the Floor." The resident landed on her stomach with her head near the front wheels of the bed and her legs near the back wheels. Her right lower leg struck the metal frame of the bedside table, causing severe bleeding.
LVN B, the charge nurse that night, was called to the room by CNA A and found the resident nude on the floor. He described the scene in his progress note: the resident's "lower extremities lay across the legs of the bedside table, while her head was partially resting against wheels of bed."
The resident was alert and oriented throughout the incident. After staff used a mechanical lift to return her to bed, they determined the laceration on her right thigh required immediate medical intervention. Emergency medical services transported her to the hospital, where doctors discovered she had suffered a left comminuted intertrochanteric fracture — a complex break in the femur with multiple bone fragments.
Hospital records show the resident "presented to the ER after a fall" and that "when they were changing the sheets she fell out of bed." The large V-shaped skin tear was stapled in the emergency room.
The facility's administrator interviewed CNA A the day after the incident. When asked if she knew how to read the Kardex — the electronic system that displays each resident's care requirements — CNA A said she did. But when asked if she had checked it the morning of the incident, she replied no.
"The Administrator asked CNA A how many people it took to assist Resident #1 and with peri care as well as other ADL's and CNA A said 2 (two)," the inspection report states. "The Administrator asked CNA A if she used another person to assist Resident #1 and CNA A replied no, that the other aides were assisting other residents."
CNA A demonstrated the incident for the administrator, showing how she had raised the bed and turned the resident on her right side. "This was when [Resident #1's] left leg swung over the side of the bed causing [Resident #1] to slide off the bed landing on her stomach," according to the administrator's statement.
Multiple staff members confirmed that adequate help was available that night. LVN B told inspectors there were "plenty of staff that night to assist and no reason for her to not ask for help." He counted himself, two aides, and a nurse trainee working, plus additional staff on the rehabilitation side of the facility.
"Anyone would be crazy to take a resident her size on by themselves," LVN B said. He described the resident as being in a bariatric bed and said "it was hard for LVN B to imagine that someone would attempt changing and cleaning her alone."
When LVN B entered the room after the fall, he noted the bed was positioned dangerously high. "It looked like she [CNA A] was getting ready to change the oil on the bed — that was never safe at any time for any patient especially someone with Resident #1's weight to have a bed that high."
CNA C, who helped retrieve the mechanical lift to get the resident off the floor, told inspectors that "because of Resident #1 was a big woman, she would have known that Resident #1 was a 2 (two) person assist" even without prior experience caring for her.
"It was never appropriate to proceed with just one person if the resident was listed in the Kardex as a 2 (two) person assist," CNA C said. "If the Kardex says the Resident require a 2 (two) person assist, you wait until you have 2 (two) people to assist."
CNA A admitted to inspectors that she "was not trained on how to use the Kardex but did know that Resident #1 was a 2 (two) person assist when changing or moving Resident #1." She said she had not been asked to return to work since the incident.
The facility's assistant director of nursing called the violation "negligence because they did not provide the safest level of care." The director of nursing, who had been in the position for a week and a half at the time of the inspection, agreed that failing to follow the ADL transfer status constituted negligence.
A family member told inspectors that "the facility staff, rolled [Resident #1] right off the bed" and confirmed the resident had "30 staples and 7 stitches and a broken hip." The family member said there was a policy requiring two people to assist the resident with any care.
The resident was discharged from the hospital to another facility and could not be reached for comment during the inspection.
Federal inspectors found the facility's corrective actions included mandatory training for all 77 direct care staff on using the Kardex system to determine assistance levels. Seventy-five staff members completed the training, with two part-time employees scheduled for training before their next shifts.
The immediate jeopardy citation was removed April 10, but the facility remained out of compliance at a widespread level due to systemic issues with staff following care plans. The violation placed residents at risk for "negligence, injury, and hospitalization," according to the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accel At College Station from 2025-04-10 including all violations, facility responses, and corrective action plans.