Failure to Complete Trauma Assessments and Care Plans for Residents with Trauma Histories
Penalty
Summary
The facility failed to complete trauma care assessments and develop corresponding care plans for two residents with known histories of trauma. Both residents were identified on the facility matrix as having PTSD or trauma, and their Minimum Data Set (MDS) assessments indicated cognitive impairment, anxiety, and depression. For one resident, the care plan addressing psychosocial well-being was created several months after admission, and no trauma assessment was found in the medical record. The social services staff confirmed that no trauma assessment had been completed for this resident, despite being aware of her trauma history. For the second resident, the MDS showed she was not cognitively intact and had diagnoses of anxiety and depression. The resident's guardian reported that trauma was not indicated in the facility's referral, and the social services staff acknowledged that no formal trauma assessment was completed upon admission. The Director of Nursing confirmed that trauma assessments should be completed within 14 days of admission and that neither resident had a trauma assessment or a starting point for treatment documented in their records. Facility policy requires trauma screening within 14 days of admission, but this was not followed for these residents.