Failure to Develop Trauma-Informed Care Plan for Resident with Trauma History
Penalty
Summary
The facility failed to identify triggers and develop a care plan with goals and interventions for a resident with a history of trauma. Despite documentation in a trauma-informed screening form that the resident had experienced abuse in the past and could experience mood swings, confusion, disorientation, and depression, the resident's comprehensive care plan did not include trauma-informed care planning, did not address the resident's trauma history, and did not identify any triggers or prevention strategies. Recommendations for trauma-informed care planning and specific interventions were documented in a spiritual care progress note, but these were not incorporated into the resident's care plan. Interviews with staff confirmed that the expectation was to develop individualized care plans with triggers and interventions for residents with a history of trauma, but this was not done for the resident in question. The resident had a diagnosis of depression and moderate memory impairment, and had reported an incident of being punched by staff, which was documented and discussed with the family. However, the lack of a trauma-informed care plan persisted despite these assessments and recommendations.