Failure to Complete Trauma Assessment and Care Planning for Resident with PTSD
Penalty
Summary
The facility failed to complete a timely trauma assessment and did not develop or implement an individualized, person-centered care plan to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). Policy review indicated that nursing staff are to be trained on trauma screening tools, trauma assessment, and identification of triggers associated with re-traumatization, and that universal screening for trauma should be implemented. However, review of the resident's clinical record, hospital discharge summary, and the CMS 802 form confirmed the diagnosis of PTSD, but there was no evidence of a trauma history screening, documentation, or care planning related to trauma-informed care as required by facility policy. Further review of the resident's care plan did not include the resident's PTSD diagnosis, symptoms, or triggers. During an interview, the DON stated that the facility does not complete a trauma assessment because it is not available in the electronic record, although a form exists for this purpose. It was also revealed that the Social Worker would be responsible for completing the trauma-informed care assessment, but this had not been done at the time of the review.