Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to two residents diagnosed with Post Traumatic Stress Disorder (PTSD). For one resident with a history of hemiplegia and PTSD stemming from an automobile accident and an assault, the facility did not complete a PTSD assessment or develop a care plan within 30 days of admission as required. The resident's care plan eventually identified loud noises as a trigger, but this was not addressed in a timely manner. The Social Work Director confirmed that the assessment and care plan were not completed within the required timeframe, resulting in a lack of interventions to eliminate or mitigate triggers that could cause re-traumatization. For another resident with PTSD related to combat experiences during the Vietnam War, the care plan did not include any identified triggers or documentation indicating that the resident declined to identify triggers. The Social Work Director confirmed that the facility failed to provide trauma-informed care for this resident as well. The facility's policy requires assessment of trauma history and identification of triggers upon admission, annually, and with significant change, but these steps were not followed for the two residents involved.