Failure to Provide Trauma-Informed Care and Individualized Interventions
Penalty
Summary
The facility failed to identify and address trauma-related triggers and develop individualized care plan interventions for two residents with significant trauma histories. For one resident, who had a complex medical and psychiatric background including bilateral below-knee amputations, schizoaffective disorder, substance use disorder, and a history of homelessness, sexual abuse, and family suicide, the care plan did not include trauma-informed interventions. Despite documentation of nightmares, anxiety, and a history of psychiatric hospitalizations, the social services director confirmed that no trauma assessment or trauma-specific care plan was in place, and staff were not informed of the resident's trauma history or potential triggers. Another resident, who experienced the traumatic loss of her home and pets in a house fire, was observed to be emotionally distressed and reported ongoing anxiety, depression, and stress related to her circumstances. Although her care plan addressed general psychiatric needs such as anxiety and depression, it did not include interventions specific to her trauma from the fire or the loss of her pets. The director of social services was unaware of any trauma-related care plan interventions for this resident and had not referred her to psychological services, despite a physician order for such a consult. The resident expressed that her emotional needs were unmet and that she had not received counseling or guidance regarding her living situation or trauma. Both cases demonstrated that the facility did not conduct adequate trauma assessments or develop trauma-informed care plans, despite clear evidence of traumatic experiences and ongoing emotional distress. The lack of individualized interventions and failure to inform staff of residents' trauma histories resulted in the potential for re-traumatization and unmet emotional needs, as staff were not equipped to recognize or mitigate trauma-related triggers during care.