Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care and culturally competent services for a resident with a diagnosis of post-traumatic stress disorder (PTSD). The resident, who had a history of acute and chronic respiratory failure, type 2 diabetes, bipolar disorder, depression, adjustment disorder, and ADHD, reported ongoing triggers and flashbacks related to a past car accident, specifically noting sensitivity to loud noises. Record review showed that the resident's comprehensive care plan did not include any interventions or plans addressing PTSD. Staff interviews revealed that a trauma-informed care observation, which is typically completed on admission to identify triggers and inform the care plan, was not conducted for the resident upon their most recent admission. The social worker was unaware of the resident's PTSD diagnosis due to the lack of this assessment, and the care plan was not updated to reflect the resident's needs.