Failure to Complete Trauma Evaluation and Care Plan for Resident with Trauma History
Penalty
Summary
The facility failed to complete a thorough trauma care evaluation and develop a comprehensive, person-centered care plan addressing past trauma and triggers for one resident. The resident, who had diagnoses including complete paraplegia, anxiety disorder, and depression, reported a history of being shot in the back, which resulted in paralysis and ongoing depression. During the psychiatric intake, the resident disclosed this trauma, and during an interview, stated that loud noises, such as staff slamming doors, triggered memories of the gunshot event. Despite this, the trauma care evaluation was incomplete, with only the first question marked as declined and the remaining questions left blank. The facility's policy required further information gathering from family or medical records if the resident declined to participate, but this was not done. Additionally, a review of the resident's care plans revealed that there was no care plan addressing the resident's past trauma or potential triggers, despite staff being aware of the trauma history. The Social Services Director acknowledged that more information should have been gathered and documented, and the DON confirmed that a care plan should have been created to address the trauma and triggers. The facility's policy required individualized care plans to minimize triggers and re-traumatization, but this was not implemented for the resident in question.