Failure to Assess and Care Plan for Trauma History in Resident with PTSD
Penalty
Summary
The facility failed to assess and address the trauma history of a resident with a diagnosis of PTSD, insomnia, REM sleep behavior disorder, depression, psychotic disorder, and anxiety. Upon admission, there was no evidence in the medical record that a trauma assessment was completed to identify potential triggers, despite facility policy requiring universal screening and individualized care planning for trauma survivors. The comprehensive care plan referenced the resident's PTSD and included general interventions, but did not specify any individualized triggers related to the resident's trauma history. Interviews with facility staff revealed that the social worker did not complete the required trauma evaluation on admission or during subsequent quarterly assessments, even though the resident had a known diagnosis of PTSD. The social worker acknowledged that the evaluation should have been conducted and, given the resident's cognitive impairment, should have involved the health care proxy, but this was not done. The DON confirmed that trauma evaluations and identification of triggers should be completed for all residents, especially those with PTSD, but was unsure why it was not done in this case.