Failure to Identify and Address Trauma Triggers in Resident Care Plan
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to provide trauma-informed care for one resident with a history of significant trauma, including childhood separation, time in an orphanage, sexual assault, and experiencing a tornado. The resident's diagnoses included Generalized Anxiety Disorder, Psychotic Disturbance, Mood Disturbance, Major Depressive Disorder, and Hallucinations. Despite this history, the resident's social assessment and care plan did not identify or document any potential triggers or emotional support needs related to past trauma. Interviews with facility staff confirmed that the care plan and medical record lacked this information, and it was also noted that the facility did not have a policy on trauma-informed care.