Failure to Integrate Trauma Informed Care into Resident Care Plan
Penalty
Summary
The facility failed to integrate trauma informed care into the care plan for one resident who was admitted for rehabilitation following hospitalization. Documentation showed that the resident was cognitively intact and had a history of trauma from adolescence into adulthood, as well as a mood disorder that warranted evaluation for mental health services. Despite this, a review of the electronic health record revealed there was no care plan addressing trauma informed care for this resident. Interviews with facility staff, including the Social Services Director, Resident Care Manager, and Director of Nursing, indicated a lack of awareness regarding the resident's trauma history and mental health needs. Staff were uncertain about how mental health providers communicated relevant information to the facility and how such information should be incorporated into the resident's care plan. As a result, the resident's trauma history and mental health concerns were not addressed in their care planning process.