Failure to Conduct Trauma Assessments for Residents
Penalty
Summary
The facility failed to conduct trauma assessments for three sampled residents, each with significant medical and psychosocial histories. For one resident, the admission record showed diagnoses including type 2 diabetes, dementia, and chronic pain, with documentation of fluctuating decision-making capacity and moderate cognitive impairment. After an incident where the resident reported being struck, further review and family input revealed the report was likely a trauma response triggered by pain and past experiences. Despite these indicators, there was no documented trauma assessment in the resident's records. A second resident, with a history of diabetes with neuropathy and suicidal ideations, also exhibited fluctuating capacity for decision-making and moderate cognitive impairment. This resident required substantial assistance with daily activities. Review of clinical records confirmed that no trauma assessment was documented for this individual, despite their complex psychosocial and medical needs. A third resident, admitted with a recent fracture and cerebral infarction affecting the dominant side, also had moderate cognitive impairment and required significant assistance with personal care. Again, no trauma assessment was found in the records. Interviews with facility staff revealed confusion regarding responsibility for trauma assessments, with the Social Services Director and Director of Nursing each indicating it was the other's responsibility. Facility policy required trauma-informed care and culturally competent services, but these were not implemented as trauma assessments were not completed for the residents involved.