Failure to Provide Trauma-Informed, Individualized Care for Resident with PTSD
Penalty
Summary
The facility failed to identify trauma-based triggers and implement individualized interventions for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident's electronic medical record documented diagnoses of PTSD, schizoaffective disorder, and anxiety, with a recent assessment indicating intact cognition and active PTSD symptoms such as nightmares, hypervigilance, and being easily startled. The care plan noted the diagnosis of PTSD and referenced annual trauma-based assessments, but lacked specific information about the trauma, potential triggers, or personalized coping interventions. Observations showed the resident exhibiting guarded behavior, such as keeping curtains closed and isolating in a dark room. Interviews with staff revealed a lack of awareness regarding the resident's PTSD diagnosis and absence of detailed trauma-related information or interventions in the care plan or Kardex. The facility's policy required trauma-informed, culturally competent care, but the documentation and staff knowledge did not reflect individualized planning or identification of trauma triggers for the resident. This deficiency placed the resident at risk for decreased psychosocial well-being and ineffective treatment.