Failure to Provide Trauma-Informed, Person-Centered Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who had a history of serving two tours in Vietnam and experienced nightly nightmares prior to medication intervention, was admitted with a diagnosis of PTSD. Although there was a physician's order for Prazosin HCL to address nightmares related to PTSD, the resident's care plan did not identify PTSD symptoms, triggers, or specific interventions to minimize triggers and prevent re-traumatization. During interviews, the resident confirmed ongoing symptoms prior to medication, and facility leadership acknowledged that they could not demonstrate the provision of culturally competent, trauma-informed care in accordance with professional standards. The care plan lacked documentation of the resident's PTSD-related needs, experiences, and preferences, and did not include strategies to eliminate or mitigate potential triggers for re-traumatization.