Failure to Identify and Assess Resident Trauma Histories
Penalty
Summary
The facility failed to implement a protocol to identify past trauma experienced by residents, specifically for two residents with severe cognitive impairment and diagnoses including dementia and post-traumatic stress disorder (PTSD). Record reviews for both residents revealed that no trauma-informed care (TIC) assessments were present in their files, despite one resident's family member reporting a significant history of trauma related to military service and PTSD. Interviews with facility staff confirmed that there was no process or screening tool in place to assess trauma history or triggers for residents admitted with PTSD. A review of the facility's own policy indicated that trauma screening should be part of the comprehensive assessment, but staff acknowledged that this was not being done. The electronic health record system did not contain TIC assessment information for the residents' initial admissions, and no documentation of such assessments was provided. As a result, the facility did not identify trauma triggers for these residents, which was a direct violation of their stated policies and procedures.