Inaccurate Trauma Informed Care Assessments for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that all participants in the assessment process had the requisite knowledge to complete accurate trauma informed care assessments for four residents with severe cognitive impairment. The Social Worker conducted multiple trauma informed care assessments for these residents, all of whom were unable to be interviewed due to their cognitive status. Despite the residents' inability to participate, the assessments were completed and consistently scored as indicating no evidence of trauma, based solely on the absence of resident-reported trauma. The facility's policy required a multi-pronged approach to identifying a resident's trauma history, including direct questioning, screening tools, and review of medical and social histories. However, for the residents in question, the Social Worker relied on interviews with staff and family members, as well as personal knowledge of the residents, rather than direct resident input. The assessments were still completed using a resident question-based tool, which was not appropriate for individuals with severe cognitive impairment who could not respond to the questions. The residents involved had significant medical histories, including Alzheimer's disease, multiple sclerosis, cerebral palsy, dementia, and other conditions resulting in severe cognitive and physical impairments. All required extensive assistance with activities of daily living and were unable to communicate effectively for the purposes of the trauma informed care assessment. The repeated use of an interview-based assessment tool for these residents resulted in inaccurate documentation of their trauma histories.