Failure to Develop Trauma-Centered Care Plan for Resident with Abuse History
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing trauma and abuse for a resident with a history of being verbally and physically abused by a former spouse. Despite the facility's policy requiring care plans to address medical, physical, mental, and psychosocial needs, and to be reviewed and revised by the interdisciplinary team after each assessment, the resident's care plan did not include trauma-centered interventions or address behaviors such as verbal aggression and yelling at others. The resident, who has multiple diagnoses including muscle weakness, diabetes with neuropathy, atrial fibrillation, chronic kidney disease, and bilateral below-knee amputations, reported being abused in the past and described recent incidents of physical altercations with another resident. Interviews with facility staff confirmed that the resident had discussed past abuse and exhibited verbally aggressive behaviors, but no trauma-centered care plan or behavioral interventions were documented in the medical record. The Director of Nursing acknowledged the absence of a person-centered care plan and specific interventions for the resident's behaviors, confirming that the deficiency was present at the time of the survey.