Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who had a history of severe trauma related to military service, was admitted with multiple diagnoses including PTSD, hypertension, and peripheral vascular disease. The resident's assessment indicated severe cognitive impairment and a need for substantial assistance with activities of daily living and mobility. Despite these needs, there was no evidence that the facility addressed the resident's PTSD in their care planning or daily care. Interviews with facility staff, including a CNA, LVN, Director of Staff Development, and the Director of Nursing, revealed a lack of awareness and training regarding PTSD. Staff members were either unaware of the resident's PTSD diagnosis or lacked knowledge about PTSD symptoms, triggers, and appropriate interventions. The Director of Staff Development and the Director of Nursing both confirmed that staff had not received in-service training specific to PTSD, and there was no care plan developed with PTSD interventions for the resident. A family member expressed concern that the facility had not addressed the resident's PTSD symptoms and was unsure if staff were even aware of the diagnosis. Review of the facility's policy indicated that behavioral health services, including trauma-informed care and staff education on PTSD, were required. However, these policies were not implemented for the resident in question, resulting in inadequate attention to the resident's trauma-related needs.