Failure to Complete Trauma Assessments and Care Plans for Residents with Trauma Histories
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care by not completing required Social Service and trauma assessments for two residents with significant histories of trauma. One resident, admitted with Alzheimer's disease, dementia, depression, and anxiety, had moderate cognitive impairment and a known history of trauma from the loss of close family members. Despite meeting with the resident and family at admission and being aware of the trauma, the Social Worker did not complete or document a trauma assessment or develop a care plan with individualized interventions. The Social Service assessment for this resident was also found to be over 200 days overdue. Another resident, admitted with Parkinson's disease and dementia, also had moderate memory impairment and behavioral symptoms. Documentation in the paper medical record indicated a traumatic and violent event in the resident's youth, but no Social Service assessment or trauma assessment was completed or documented. The Social Worker acknowledged being behind on assessments and not implementing trauma assessments for any residents, despite being recently educated on the requirement. The care plan for this resident did not reflect their history of trauma, and the Social Service assessment was 46 days overdue.