Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for three residents who are trauma survivors. Resident R58, admitted with a history of gunshot wounds and significant pain, did not have an assessment for trauma-informed care or PTSD in their evaluations. Despite experiencing anxiety and depression, their care plan lacked goals and interventions related to trauma-informed care. Additionally, Resident R58 expressed concerns about safety and privacy, which were not adequately addressed by the facility, as evidenced by the placement of their name outside their door against their wishes. Similarly, Residents R20 and R30, both diagnosed with anxiety, depression, and PTSD, did not have assessments for trauma-informed care or PTSD in their evaluations. Their care plans also failed to include goals and interventions related to their PTSD. The Director of Nursing acknowledged the facility's failure to provide trauma-informed care in accordance with professional standards, considering the residents' past experiences and preferences to prevent re-traumatization.
Plan Of Correction
Resident #58 continues to reside in the facility. Password for visitors has been added to her profile per resident request. Residents #20, 30 & 58 will have Trauma Informed Assessment and Care plan with interventions. Residents who have experienced Trauma in their lives have the potential to be affected. Social Services and Nursing will assess residents with Trauma Informed Assessment and develop care plans with interventions for the residents that require them. Facility administrator or designee provided education to Social Services Director and Licensed Nursing Staff regarding the need to assess residents for Trauma and develop care plans with interventions. Social Services will conduct weekly audit on all new admissions for 4 weeks, then monthly for 2 months to ensure that a Trauma Informed Care Assessment has been completed and if necessary, care plan with interventions has been developed. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.