Failure to Provide Trauma-Informed, Culturally Competent Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to two residents with significant histories of trauma, as required by its own policies and professional standards. For one resident with diagnoses including dementia, major depressive disorder, traumatic brain injury, and schizophrenia, the care plan documented a history of sexual assault, traumatic brain injury, incarceration, and suicidal ideations. However, the care plan did not include the resident's history of homicidal ideations, nor did it provide behavior monitoring for suicidal or homicidal ideations. Staff interviews revealed that direct care staff were unaware of the resident's history of suicidal or homicidal ideations, despite this information being documented in the PASRR Level II evaluation and psychiatric notes. The facility also failed to assess and identify potential triggers that could cause re-traumatization or behaviors towards others for this resident. For the second resident, who had diagnoses including PTSD, schizoaffective disorder, and bipolar disorder, the care plan noted a history of sexual assault and PTSD but did not include individualized, person-centered, non-pharmacological approaches to address the resident's needs. The social history assessment lacked documentation of the specific support needed for the resident's PTSD, and there was no evidence that the facility completed an assessment to identify or mitigate triggers that could cause re-traumatization. The resident reported that the facility had not asked about her past traumatic event, and staff interviews confirmed a lack of awareness and assessment regarding trauma triggers. Overall, the facility did not perform universal screening or in-depth assessment to identify trauma triggers for these residents, nor did it develop or implement individualized care plans and interventions to address their trauma histories. Staff were not adequately informed of the residents' trauma-related risks, and the care plans did not reflect the necessary information to guide trauma-informed care, resulting in a failure to meet the residents' psychosocial and emotional needs as outlined in facility policy.