Failure to Provide Trauma-Informed Care and Staff Training
Penalty
Summary
The facility failed to provide trauma-informed care and culturally competent services to two residents with trauma-related diagnoses. Both residents had documented histories of PTSD and other mental health conditions, yet their care plans, assessments, and daily care documentation lacked any reference to trauma, triggers, or specific interventions related to their trauma histories. There was no evidence that trauma assessments or screenings were completed upon admission or thereafter for either resident, and their care plans did not address trauma-informed approaches as required by facility policy. Staff interviews revealed a lack of awareness and training regarding trauma-informed care. The Director of Nursing (DON), Certified Nursing Assistant (CNA), Registered Nurse (RN), and Social Services Director (SSD) all confirmed that no trauma assessments had been completed for the residents in question, and that staff had not received training on trauma-informed care, screening tools, or strategies to address trauma-related triggers. The SSD acknowledged that trauma assessments should have been completed within 48 hours of admission to inform the baseline and comprehensive care plans, but this was not done for either resident. Review of the facility's policy on trauma-informed care indicated that all staff were to be trained on trauma, its impact, and the use of screening tools, with universal screening of residents for trauma. However, there was no evidence that these policy requirements were met. The lack of trauma assessments, absence of trauma-related care planning, and insufficient staff training directly contributed to the facility's failure to provide trauma-informed care to residents with known trauma histories.
Plan Of Correction
Resident #25 and #140 were immediately assessed and found to have no adverse effects. All residents have the ability to be affected. Resident #25 and #140 chart immediately reviewed, trauma-informed assessment was added by Social Services. All residents were reviewed to ensure they had trauma-informed care plans in place. Education was provided to all staff by the DON on 5/22/25 regarding trauma-informed care importance and policy. The DON/Designee will complete weekly audits of new hire paperwork to ensure review of trauma-informed care for 4 weeks to ensure compliance. Results will be reviewed in QAPI plans.