COLLEGE STATION, TX - A state inspection at Accel at College Station nursing home revealed that staff failed to provide required two-person assistance for a resident's care, resulting in a laceration and fractured hip that required hospitalization. The violation, discovered during an April 2025 complaint investigation, prompted immediate corrective actions including staff termination and facility-wide retraining on care protocols.
Critical Safety Protocol Violation Results in Serious Injury
The Texas Department of Health and Human Services investigation found that on March 26, 2025, a certified nursing assistant (CNA) attempted to provide care alone to a resident whose care plan specifically required two staff members for assistance. This violation of the resident's documented care requirements directly contributed to an incident where the resident sustained both a laceration and a fractured hip, necessitating immediate transfer to a hospital.
The severity of this incident cannot be overstated. Hip fractures in elderly nursing home residents carry mortality rates of 20-30% within the first year, with many survivors experiencing permanent mobility limitations. When nursing homes fail to follow two-person assist protocols, they dramatically increase the risk of falls and injuries during transfers and repositioning activities.
According to the inspection report, the facility's own documentation clearly indicated that Resident #1 required two-person assistance for activities of daily living. The Kardex system - a quick-reference tool used by nursing staff to track resident care requirements - specifically noted this two-person requirement. Despite this clear directive, CNA A proceeded to provide care without securing assistance from another staff member.
Systemic Failures in Staff Training and Protocol Adherence
The investigation revealed broader systemic issues beyond the single incident. When surveyors examined the facility's practices, they discovered that multiple staff members were not consistently referring to the Kardex system before providing resident care. This fundamental breakdown in communication protocols meant that staff were making assumptions about resident care needs rather than following documented requirements.
The facility's audit conducted on April 10, 2025, identified 13 residents who required two-person assistance with bed mobility. During this comprehensive review, discrepancies were found between actual care requirements and what staff understood about resident needs. These discrepancies were immediately corrected, but their existence pointed to an ongoing pattern of inadequate communication about resident care requirements.
Two-person assist protocols exist for specific medical reasons. When residents have limited mobility, cognitive impairment, or are at high risk for falls, attempting transfers or repositioning with only one caregiver can result in dropped residents, skin tears from improper handling, joint dislocations, and fractures. The physics of safely moving an adult human body often requires multiple points of support that a single caregiver cannot provide, particularly when the resident cannot bear their own weight or maintain balance.
Medical Implications and Industry Standards
Hip fractures represent one of the most serious injuries that can occur in a nursing home setting. Beyond the immediate trauma, these injuries trigger a cascade of medical complications. Prolonged immobilization during recovery increases the risk of pressure ulcers, pneumonia, blood clots, and muscle atrophy. The surgical intervention often required for hip fractures carries its own risks, particularly for elderly residents who may have multiple chronic conditions.
Industry standards dictate that care plans must be followed precisely as written. The Centers for Medicare & Medicaid Services (CMS) requires facilities to ensure that residents receive care in accordance with their comprehensive assessment and care plan. When facilities deviate from these plans, they not only violate federal regulations but also breach their fundamental duty to protect resident safety.
The two-person assist requirement is determined through comprehensive assessments that evaluate factors including the resident's weight, cognitive status, balance, strength, and cooperation level. Physical therapists and nursing professionals use standardized assessment tools to determine when mechanical lifts or multiple caregivers are necessary. These determinations are not suggestions - they are critical safety requirements based on clinical evaluation.
Corrective Actions and Staff Accountability
Following the incident, the facility implemented multiple corrective measures. The involved CNA was immediately suspended on March 26, 2025, pending investigation findings, with employment officially ending on March 31, 2025. The administrator conducted immediate retraining with the staff member on March 27, emphasizing the requirement to "refer to the Kardex prior to providing assistance to residents so that you can ensure you are providing the appropriate level of care."
The facility conducted comprehensive staff retraining between April 9-10, 2025. Of 77 direct care staff members, 75 received immediate in-service training on referring to the Kardex system and understanding two-person assist requirements. The remaining two PRN (as-needed) staff members were scheduled to receive training before their next shifts.
The Corporate Clinical Service Director led facility-wide education initiatives, working with the nurse management team to ensure all staff understood the critical importance of checking care requirements before providing assistance. The facility also implemented new monitoring systems, including daily reviews of resident care requirements for the first week, weekly reviews for one month, and monthly reviews thereafter until compliance could be sustained for three consecutive months.
Additional Issues Identified
During the investigation, surveyors identified several related concerns that contributed to the overall pattern of care deficiencies. The facility's system for communicating changes in resident conditions required strengthening, as evidenced by the need for Assistant Directors of Nursing to conduct daily reviews for three months to ensure Kardex accuracy.
The Medical Director was not immediately notified of the incident, with notification occurring only on April 9, 2025 - nearly two weeks after the March 26 incident. This delay in physician notification could have impacted medical decision-making and care coordination for affected residents.
The facility also needed to strengthen its quality assurance processes. An impromptu Quality Assurance and Performance Improvement meeting was convened on April 9, 2025, involving seven key staff members including the Administrator, Regional VP of Operations, Director of Nursing, both Assistant Directors of Nursing, Clinical Services Director, and facility Medical Director.
Long-Term Monitoring and Compliance
The facility established a comprehensive monitoring program to prevent recurrence. The Director of Nursing or designee will conduct random observations of ADL care, particularly focusing on residents requiring two-person assistance. These observations will occur daily for one week, then weekly for one month, and monthly thereafter until the facility demonstrates sustained compliance for three consecutive months.
New employee orientation protocols were revised to ensure all newly hired nursing staff receive training on Kardex utilization and two-person assist requirements before beginning independent work. The administrator committed to weekly reviews of audit reports to ensure nurse managers maintain compliance with the corrective action plan.
While the immediate threat to residents was addressed and the "immediate jeopardy" designation was removed on April 10, 2025, at 7:10 pm, the facility remained out of compliance at a "no actual harm" level. Surveyors noted that the facility needed time to evaluate the effectiveness of its corrective systems before full compliance could be verified.
The incident at Accel at College Station serves as a stark reminder of the critical importance of following established care protocols. When facilities fail to ensure staff adherence to documented care requirements, residents pay the price through preventable injuries that can fundamentally alter their quality of life. The comprehensive corrective actions implemented suggest recognition of these failures, but only sustained monitoring and culture change will prevent future incidents.
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.
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