Failure to Develop and Implement Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to assess, develop, and implement a comprehensive care plan addressing a resident's documented PTSD diagnosis and potential trauma triggers. Despite multiple social services trauma screens and progress notes indicating a history of trauma, PTSD, and specific traumatic experiences, the care plan did not reflect individualized interventions for trauma or identify known triggers. The care plan focused on adjustment issues and claustrophobia but omitted interventions related to the resident's history of sexual abuse and trauma, even though these were documented in the resident's records. Interviews with facility staff, including CNAs, LPNs, the DON, and the psychiatrist, revealed a lack of awareness regarding the resident's PTSD diagnosis and trauma history. Staff members were not informed of the resident's trauma-related needs or trained to identify or respond to potential triggers. The psychiatrist and psychologist were also unaware of the full extent of the resident's trauma history, and the psychologist noted that the resident's fear and refusal of care could be related to unaddressed trauma. The absence of trauma-informed care planning led to staff not being equipped to provide appropriate support or interventions. Documentation reviews showed inconsistencies in the recognition and care planning for PTSD and trauma. The resident's MDS did not list PTSD or trauma-related diagnoses, and trauma screens often left care plan updates blank or marked as not applicable. The facility's policy required trauma-informed, person-centered care planning, but this was not followed in practice for this resident, resulting in a failure to meet the resident's mental and psychosocial needs as identified in assessments.