Failure to Provide Trauma-Informed Care and Assessment
Penalty
Summary
The facility failed to provide trauma-informed care for two residents with behavioral and emotional care needs, both of whom had diagnoses including PTSD. According to the facility's own Trauma Informed Care Policy, residents should be screened for traumatic events, and individualized care plans should be developed to address trauma triggers and interventions. However, for both residents, there was no evidence in their clinical records that trauma assessments were completed or that care plans addressing trauma triggers were developed. Staff interviews confirmed a lack of awareness regarding the residents' trauma histories or potential triggers, and social services staff acknowledged that required trauma screenings and care planning had not been completed for these residents. One resident, admitted with schizophrenia and PTSD, reported experiencing auditory hallucinations and distress but could not recall being asked about trauma triggers. Staff members were unaware of any specific triggers or interventions in place for this resident. The second resident, admitted with major depressive disorder and PTSD, also had no documented trauma assessment or care plan. This resident stated that no one had discussed the cause of their PTSD or potential triggers, and staff were similarly unaware of any trauma-related needs or interventions. The lack of trauma-informed assessments and care planning placed these residents at risk for re-traumatization.