Failure to Complete Trauma Screening and Assessment for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a known history of trauma and a diagnosis of PTSD received trauma-informed, culturally competent care in accordance with professional standards. Upon admission, the resident's records, including the admission referral packet, MDS assessment, and admission assessment, all documented a diagnosis of PTSD and a history of trauma. Despite this, there was no evidence that a trauma screening or trauma assessment was completed upon admission or at any point since admission. The resident's comprehensive care plan did not address PTSD or identify potential triggers for re-traumatization, and social services notes also lacked any trauma screening or identification of triggers. Interviews with facility staff, including the Social Services Director, DON, and Administrator, confirmed that trauma screenings were expected to be completed upon admission and that a positive screening should trigger a more comprehensive assessment. However, staff were unable to locate any trauma screening or assessment for the resident in the medical record, and there was uncertainty regarding whether a diagnosis of PTSD would automatically trigger further assessment. The facility's own policy required trauma screening upon admission, annually, and as needed, with identified triggers to be incorporated into the care plan, but this was not followed for the resident in question.