Failure to Complete Trauma-Informed Assessment for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma received trauma-informed and culturally competent care in accordance with professional standards. Specifically, a male resident with diagnoses including schizoaffective disorder, bipolar type, and post-traumatic stress disorder (PTSD) did not have a trauma screening or assessment completed upon admission, despite his documented history of trauma and PTSD. The resident's comprehensive care plan did not include documentation or interventions related to his PTSD, and there was no trauma-informed care assessment found in his clinical file. Multiple staff interviews confirmed that the trauma assessment was not completed as required, and staff were unclear about the resident's triggers and appropriate interventions. The resident, who is a veteran and attributed his PTSD to his military service, reported that he had not been offered any services related to his PTSD but expressed interest in receiving such services. Staff members, including the administrator, social worker, DON, and ADON, acknowledged that the trauma-informed care assessment should have been completed and recognized the importance of identifying triggers and needs for residents with trauma histories. The facility's own policy required a multi-pronged approach to identifying trauma history and cultural preferences, but this was not followed for the resident in question.