Failure to Complete Trauma Assessment for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma received trauma-informed and culturally competent care in accordance with professional standards of practice. Specifically, the resident, who had diagnoses including post-traumatic stress disorder (PTSD), anxiety disorder, and Wernicke's encephalopathy, did not have a trauma screening or assessment completed upon admission. The resident's comprehensive care plan did not address PTSD, and there was no documentation identifying possible triggers related to the resident's trauma history. Interviews with facility staff, including the Social Worker, DON, and Administrator, confirmed that the trauma assessment was not completed as required by facility policy. The Social Worker acknowledged responsibility for trauma assessments and recognized the importance of such assessments for staff awareness and care planning. The DON and Administrator also confirmed their expectations that trauma assessments be completed on admission and identified the lack of assessment as a failure to provide appropriate care for trauma survivors.