Failure to Complete Psychosocial and Trauma Assessments on Admission
Penalty
Summary
The facility failed to provide medically-related social services to two out of four sampled residents by not completing required psychosocial and trauma assessments upon admission. For one resident with diagnoses including influenza, PTSD, and anxiety disorders, there was no trauma assessment or social services assessment completed at the time of admission. The Social Services Director confirmed that all residents should be screened for trauma on admission to ensure appropriate treatment and resources, but this was not done for the resident in question. Another resident, admitted with dementia, a fracture, a history of assault, and traumatic subarachnoid hemorrhage, also did not receive a trauma assessment or social services assessment upon admission. The Social Services staff indicated that trauma assessments were only performed if a resident had a diagnosis of PTSD, despite the resident's history of assault. The staff also stated that the social services assessment, which includes trauma-related questions, was not completed at the time of admission, as they believed they had up to a week to do so. Interviews with the Director of Nursing confirmed that trauma and psychosocial assessments should be initiated upon admission for all residents, regardless of diagnosis, to identify any needs or triggers that may require additional support. Facility policies reviewed indicated that social services and behavioral health assessments are to be completed for all new admissions to ensure the highest practicable well-being, but these were not followed in the cases identified.