CNAs Unable to Access Resident Kardex, Compromising Individualized Care
Penalty
Summary
Two certified nursing assistants (CNAs) at the facility were found to lack the competency to access and utilize the resident Kardex, a key tool for summarizing and guiding individualized resident care. During observations and interviews, both CNAs, each with approximately one month of experience at the facility, were unable to locate or access the Kardex for their assigned residents using the electronic system. One CNA was unaware that a resident under her care had a pressure injury, stating she relied solely on verbal reports from the charge nurse and had not received information about the resident's condition during shift handoff. Both CNAs confirmed they did not know how to access the Kardex, and one acknowledged that this lack of access would impact her ability to provide proper care. The Director of Staff Development confirmed that CNAs are expected to review the Kardex daily to be aware of resident care needs, and that failure to do so could result in incomplete care and worsening of conditions such as pressure injuries. Facility policy and orientation materials indicated that individualized care plans, including the Kardex, should be accessible to all caregivers and that CNAs are required to use the facility's documentation system as directed. The deficiency was identified through observation, interview, and review of facility records and policies.