Failure to Provide Behavioral Health Services for Resident with Trauma History
Penalty
Summary
The facility failed to provide necessary behavioral health services for a resident with a documented history of sexual abuse. Review of the resident's care plan showed that, although it acknowledged the history of sexual abuse and aimed to minimize traumatic symptoms, it did not include specific behavioral health interventions or considerations, such as the gender of staff providing care, that would address the resident's trauma history. The trauma assessment for the resident indicated no identified triggers or severity, despite the hospital record noting an assessment for possible sexual assault. Facility policy on trauma-informed and culturally competent care requires individualized care plans that incorporate trauma history and preferences, including those related to personal care and staff assignments. However, the resident's care plan lacked these individualized behavioral health supports. This deficiency was confirmed through review of clinical records, facility policy, and staff interviews, demonstrating a failure to ensure the resident received appropriate behavioral health services to maintain their highest practicable well-being.