Failure to Provide Trauma-Informed Care and Assess for Trauma After Resident Disclosure
Penalty
Summary
The facility failed to provide trauma-informed care in accordance with professional standards of practice for a resident with a history of trauma and mental health diagnoses. The resident, admitted with dementia, COPD, anxiety disorder, mood disorder, and depression, reported a history of childhood sexual abuse and experienced flashbacks, hallucinations, and delusions related to this trauma. Despite these disclosures, there was no evidence that the facility's social services or psychiatric providers assessed the resident for trauma following her statements, nor were any trauma-related triggers or interventions documented in her care plan or Kardex. The deficiency was identified after the resident alleged rough treatment by a CNA, which she later recanted, attributing her statements to confusion and flashbacks from past trauma. Multiple assessments and progress notes failed to document any follow-up or trauma assessment after the incident, and staff interviews revealed a lack of awareness regarding the resident's trauma history, triggers, or appropriate interventions. The facility's policy on trauma-informed care did not include procedures for assessing residents for trauma or ensuring that triggers were identified and addressed in the plan of care. Interviews with facility staff, including the administrator, social service designee, CNA, and psychiatric nurse practitioner, confirmed that the resident's trauma history was not communicated or incorporated into her care planning. The lack of documentation and communication resulted in the resident's trauma history and related care needs being unaddressed, despite her ongoing symptoms and requests for therapy related to her flashbacks.