Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify, implement, and utilize trauma-based care strategies for a resident with a documented history of post-traumatic stress disorder (PTSD). The resident's electronic medical record (EMR) included diagnoses of general anxiety disorder, schizoaffective disorder, and PTSD. The resident was dependent on staff for all activities of daily living and had a history of depression, anxiety, and recent legal issues. Despite these documented concerns, the care plan did not include specific interventions or strategies related to trauma-informed care or address the resident's PTSD. Assessments in the EMR indicated the resident experienced symptoms such as nightmares, anxiety, and feelings of detachment, but there was no evidence of ongoing trauma or PTSD-related assessments beyond an initial screening. Staff interviews revealed a lack of awareness regarding the resident's trauma history and no knowledge of trauma-specific interventions. The care plan only referenced general behavioral health consults and did not provide guidance for staff on managing trauma-related symptoms or triggers. Observations showed the resident experiencing high anxiety and physical symptoms such as shaking, which she attributed to her PTSD and anxiety. The facility's policy required comprehensive trauma screening and individualized interventions, but these were not reflected in the resident's care plan or in staff practices. The lack of trauma-informed care placed the resident at risk for decreased psychosocial well-being and increased behavioral symptoms.