Failure to Provide Trauma-Informed Care and PTSD Screening
Penalty
Summary
The facility failed to ensure that trauma-informed and culturally competent care was provided, as evidenced by the lack of screening for post-traumatic stress disorder (PTSD) and the absence of a trauma-informed care program. One resident, who had a history of military service during the Vietnam War and reported exposure to traumatic events, was not assessed for trauma or PTSD upon admission. The resident had a history of anxiety, depression, and suicidal ideation, and was prescribed anti-depressant and anti-anxiety medications. Despite these risk factors and the resident's own acknowledgment of anxiety and depression related to loss of independence, there was no documentation or assessment addressing his trauma history or military service in his medical record. Interviews with facility staff, including the DON, assistant DON, SSD/RN, and MDS coordinator, confirmed that there was no process in place to assess residents for trauma history, and no trauma-informed care assessment had been completed for the resident. The facility also lacked a trauma-informed care policy, despite its facility assessment stating that it offers services to support individuals with trauma or PTSD. The failure to implement these processes and policies resulted in the deficiency identified during the survey.