Failure to Update Care Card Leads to Resident Fall and Serious Injury
Penalty
Summary
A deficiency occurred when the facility failed to update the nurse aide care card to reflect a resident's current non-ambulatory status. The resident, who had diagnoses including unsteadiness on feet, polyneuropathy, atrial fibrillation, and cognitive communication deficit, was dependent on staff for transfers and toileting. Physician orders and therapy documentation indicated the resident was not functionally ambulatory and required assistance for transfers, but the care card did not specify the resident's ambulation status, leaving the section blank. The care card only listed a walker and wheelchair as assistive devices, without clarifying that the resident should not ambulate independently or with a walker. On the day of the incident, a nurse aide, assigned as the resident's caregiver, assisted the resident out of bed using a walker to ambulate to the bathroom. The aide did not use a gait belt and was unaware of the resident's non-ambulatory status, as the care card was not updated. During the transfer, the resident lost balance while reaching to turn on the bathroom light, causing the walker to topple and resulting in a fall. The resident sustained a traumatic subarachnoid hemorrhage, a right femoral neck fracture requiring surgery, and a right distal clavicle fracture. Interviews and documentation confirmed that the physical therapist had communicated the resident's non-ambulatory status to nursing staff and updated the physician orders, but the nurse aide care card was not revised accordingly. The Director of Nursing acknowledged that the care card failed to reflect the resident's ambulation status both before and after the change, contributing to the incident. Facility policy required care plans and care cards to accurately reflect residents' functional status, transfer methods, and ambulation ability, but this was not followed in this case.