Failure to Screen Residents for Trauma History Upon Admission
Penalty
Summary
The facility failed to ensure that all residents were screened for a history of trauma upon admission, as required by their own policy. Four residents with varying degrees of cognitive impairment and mental health diagnoses were not assessed for trauma history or triggers at the time of their admission. For example, one resident with severe cognitive impairment disclosed a history of childhood abuse and expressed ongoing concerns about personal safety, yet there was no documentation of trauma screening or assessment for trauma triggers in her record. Another resident with a history of abuse and multiple hospitalizations related to trauma was not screened for trauma upon admission, and her care plan did not specifically address her trauma history. Interviews with facility staff, including the social services manager and lead resident care manager, confirmed that there was no process in place for universal trauma screening at the time of admission. Staff indicated that only residents with a mental health diagnosis or those prescribed psychotropic medications were referred for psychiatric evaluation, and trauma-informed care had not been part of the training curriculum. Staff were unaware that trauma screening was required for all residents, regardless of diagnosis. Additional residents with diagnoses of PTSD, including one with a history of the Oklahoma City bombing and another receiving psychiatric care through the VA, were also not screened for trauma upon admission. Their care plans either did not mention PTSD or lacked interventions related to trauma. Review of the facility's policy confirmed that universal trauma screening was required, but this was not implemented for the sampled residents, resulting in a failure to provide trauma-informed and culturally competent care as outlined in facility policy.