Failure to Complete Trauma Care Evaluation for Resident
Penalty
Summary
The facility failed to conduct a trauma care evaluation for one of four sampled residents, despite facility policy requiring universal screening for trauma-informed care. The resident in question was admitted with diagnoses including rhabdomyolysis, dementia, and a history of malignant neoplasm of the breast. Upon admission, the resident had experienced a significant traumatic event, having fallen at home and remained on the floor for approximately five days before being found. The resident's Minimum Data Set indicated intact cognition and dependence on staff for several activities of daily living. During a review of the resident's records, it was found that no trauma care evaluation had been completed. The Social Services Director confirmed that a trauma care evaluation should have been performed for all residents and acknowledged missing this assessment for the resident. The facility's policy on trauma-informed and culturally competent care specifies that universal screening is required to identify the need for further assessment and care, but this was not followed in this case.