Failure to Complete Trauma Informed Care Assessment for Resident with PTSD
Penalty
Summary
The facility failed to perform a trauma informed care assessment for a resident diagnosed with post-traumatic stress disorder (PTSD) and dementia. Upon admission, the resident's record indicated a diagnosis of PTSD, and the Minimum Data Set (MDS) confirmed severe cognitive impairment and PTSD. The Social Services Director (SSD) stated that the trauma assessment, which is typically completed upon admission for residents with trauma diagnoses, was not completed because the resident declined to answer at the time. The SSD acknowledged that if a resident declines, the assessment should be attempted again, but no reassessment was documented in the resident's chart. As a result, the facility did not identify the resident's PTSD triggers, which is necessary to provide trauma informed care and minimize the risk of re-traumatization. The facility's policy requires identification of trauma triggers and the implementation of interventions to reduce exposure to those triggers, but this was not done for the resident in question. The lack of a completed trauma assessment meant that the resident's care plan did not include trigger-specific interventions as required by facility policy.