Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care and services in accordance with professional standards of practice for two residents diagnosed with Post-Traumatic Stress Disorder (PTSD). Both residents had an active diagnosis of PTSD documented in their clinical records, but their care plans did not address this diagnosis. One resident exhibited aggressive and agitated behaviors, including responding to internal stimuli and yelling at staff and peers, yet there were no care plan interventions in place to address or manage PTSD-related symptoms. Interviews with staff revealed a lack of awareness regarding the residents' PTSD diagnoses and the absence of trauma-informed interventions. The LPN assigned to one resident was unaware of the PTSD diagnosis and confirmed that no interventions had been established. The staff member responsible for MDS assessments and care plans acknowledged that both residents should have been care planned for PTSD but were not. Additionally, the social services designee admitted to not knowing the specific trauma histories of the residents and confirmed that trauma assessments did not include details necessary for appropriate care planning.