Failure to Complete Trauma-Informed Care Assessment for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care and culturally competent services to a resident diagnosed with Post Traumatic Stress Disorder (PTSD). According to the facility's policy, staff are required to conduct universal screening for trauma history and perform an in-depth assessment to identify trauma symptoms and triggers. However, review of the resident's electronic health record (EHR) from June 2024 through May 2025 revealed that no trauma-informed care assessment was completed for the resident, despite their documented PTSD diagnosis. During interviews, the Social Services Director confirmed that there was no trauma-informed care assessment present in the resident's EHR and acknowledged that one should have been completed. The Administrator also stated that a trauma-informed assessment was expected for the resident. This lack of assessment was identified through both record review and staff interviews, indicating noncompliance with the facility's own policy and professional standards of practice.