Failure to Assess and Plan Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to assess and address the trauma history and related care needs of a resident with a documented diagnosis of PTSD, anxiety, and depression. Despite the facility's policy requiring trauma assessments and individualized care planning, there was no evidence in the medical record that staff collaborated with the resident or other healthcare professionals to identify the nature of the trauma, its effects, or potential triggers. The psychiatric nurse practitioner's documentation acknowledged the PTSD diagnosis but did not provide details about the trauma or interventions to mitigate re-traumatization. Interviews with the resident confirmed a history of significant trauma in both childhood and adulthood. The Director of Social Services admitted to missing the trauma assessment and care plan for this resident, despite being aware of the PTSD diagnosis. Additionally, the Unit Manager and Regional Nurse were unable to identify the nature of the resident's trauma or any specific triggers, indicating a lack of comprehensive assessment and person-centered planning as required by facility policy.