Failure to Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to implement trauma-informed care for a resident diagnosed with major depressive disorder, PTSD, and anxiety disorder. The resident's care plan identified issues related to past trauma, including angry outbursts, anxiety, changes in sleep, depression, emotional swings, and refusal of care. However, the care plan did not include any specific triggers or details about the resident's original trauma to help staff avoid re-traumatization. Interventions listed were general, such as encouraging participation in activities, providing time to express feelings, and consulting with psychological services, but lacked trauma-specific strategies. Interviews with staff revealed a lack of awareness and understanding regarding the resident's PTSD and associated triggers. A CNA was unaware of any residents with PTSD on her hallway, and an LPN only identified the diagnosis after reviewing the record, but could not specify any triggers or appropriate approaches. The Social Services Director also could not identify specific triggers or events leading to the resident's symptoms and only updated the care plan after an audit. The facility's policy required identification and mitigation of trauma triggers, but this was not reflected in the resident's care plan or staff knowledge at the time of the survey.