Failure to Assess and Provide Trauma-Informed Care After Alleged Sexual Abuse
Penalty
Summary
A deficiency occurred when the facility failed to assess a resident with a history of post-traumatic stress disorder (PTSD), adjustment disorder, and other mental health diagnoses for additional trauma or psychosocial needs following an allegation of sexual abuse. The resident, who had been in the facility since 2004, was reported to have been touched inappropriately by another resident. Although the incident was reported to the state agency, and the resident's provider and guardian were notified, there was no documentation that a trauma assessment was completed after the incident. The resident's care plans identified her as being at risk for behavioral alterations related to trauma and PTSD, and interventions included considering past trauma and collaborating with psychology and social services. Despite these documented risks and the facility's policy on trauma-informed care, the most recent trauma assessment on record was over a year old and predated the incident. Interviews with facility staff confirmed that trauma assessments were expected after such incidents, but none was completed in this case. The social services director acknowledged the importance of trauma assessments post-incident but had only spoken with the resident, who declined to discuss the event further. Additionally, the resident's psychology provider was not notified of the incident, contrary to facility expectations and best practices. The provider stated she would typically be informed of such events to assess for signs of distress or behavioral changes. Facility policy required identification and care planning for trauma history, but the lack of a timely trauma assessment and communication with the psychology provider after the allegation constituted a failure to provide appropriate treatment and services for the resident's mental and psychosocial well-being.