Failure to Timely Assess and Identify Resident Trauma History
Penalty
Summary
The facility failed to adequately assess and identify past trauma for a resident admitted with diagnoses including major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder. Upon review, it was found that no trauma screening was conducted at the time of admission, despite the facility's policy requiring such screening. The psychosocial assessment, which included only one question about trauma, was not completed until more than two months after admission. Additionally, the Social Services Life Event Checklist, intended to assist in creating a trauma-informed care plan, was not completed in a timely manner and all responses were marked as not applicable. Interviews with the Social Services Director and staff revealed that there was no formal trauma screen form in use, and the required trauma-informed care training had only been completed by the Social Services Director, with no evidence of completion by other social services staff. The resident, who is cognitively intact, disclosed a significant traumatic event from his past during an interview, which had not been previously identified or addressed in his care planning.