Failure to Train NA on Kardex Use Leads to Resident Fall and Fractures
Penalty
Summary
A nursing assistant (NA) was found to be untrained and not competent in using the kardex system, which is a quick-reference tool for resident care information. The NA had not received education on what the kardex was or how to access it during orientation or while being trained on the floor. Instead, the NA relied on asking residents and other staff about care needs prior to learning about the kardex. The NA only received training on the kardex after an incident occurred, and review of the orientation packet confirmed there was no documentation of kardex training. This lack of training contributed to an incident where the NA attempted to assist a dependent resident with an impaired gait in ambulating to the bathroom. The NA left the resident standing unsupported while turning away to dispose of a brief, resulting in the resident falling and sustaining a left wrist fracture and a left hip fracture. Interviews with staff and review of records confirmed that the NA was not aware of the kardex or its use until after the incident, and the Director of Nursing was unaware of this training gap until it was brought to her attention.