Failure to Complete Trauma-Informed Assessment for Resident with PTSD
Penalty
Summary
The facility failed to adequately assess a resident with a diagnosis of post-traumatic stress disorder (PTSD) for trauma triggers and effective interventions to prevent re-traumatization. Upon admission, the resident was cognitively intact and had a history of PTSD, anxiety, depression, and a recent fall with fracture. The admission Minimum Data Set (MDS) indicated the resident required substantial assistance with activities of daily living and was always incontinent. The facility's Trauma-Informed Care Observation form for this resident was incomplete, with several key questions about traumatic experiences, emotional impact, triggers, and coping strategies left unanswered. The resident's care plan included goals and interventions related to trauma and PTSD, such as identifying triggers and utilizing coping strategies, but the necessary assessment to inform these interventions was not completed. Interviews with facility staff, including the Social Services Coordinator and Regional Nurse, confirmed that the trauma-informed care assessment was not fully completed as required by facility policy. The facility policy stated that all residents should be assessed for a history of trauma upon admission using the designated observation tool, which was not done in this case.