Lack of Trauma-Informed Care Policy
Penalty
Summary
The facility was found to be deficient in having a written policy for trauma-informed care. This deficiency was identified through record reviews and staff interviews. A quarterly Minimum Data Set (MDS) assessment for a resident, dated December 5, 2024, indicated that the resident was cognitively intact and had a diagnosis of Post Traumatic Stress Disorder (PTSD). The resident's care plan, dated September 11, 2024, noted a potential for mood problems related to PTSD. However, during an interview with the Nursing Home Administrator on January 22, 2025, it was confirmed that the facility lacked a policy regarding trauma-based assessments, which is necessary to address the resident's needs effectively.
Plan Of Correction
An assessment has been conducted for resident R62 with triggers identified. A house wide audit has been done for all residents with a Post Traumatic Stress Disorder diagnosis. All identified residents will have an assessment completed to identify triggers and interventions. Nursing and social services will be educated on a newly created Trauma Informed care policy. The Nursing Home Administrator will audit new resident diagnoses and new admissions for diagnoses of post-traumatic stress for 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.
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