Failure to Implement Trauma-Informed Care Planning for Residents with PTSD
Penalty
Summary
The facility failed to implement a comprehensive care plan that addressed trauma-informed care for two residents with trauma-related diagnoses. For one resident with dementia, major depressive disorder, generalized anxiety disorder, and PTSD, there were no trauma screenings or assessments completed since admission, and no documentation in the care plan, nursing notes, or physician notes regarding trauma, triggers, or trauma-informed interventions. The resident's care plan only referenced cognitive impairment, depression, anxiety, and a history of alcohol abuse, without any mention of trauma-informed care. The nursing assistant Kardex also lacked any information related to trauma-informed care for this resident. Interviews with facility staff confirmed that no trauma assessments were completed and that trauma-related needs were not included in the care plan or daily care routines. Similarly, another resident with PTSD, major depressive disorder, generalized anxiety disorder, and other medical conditions did not have trauma-informed care addressed in the baseline care plan. The baseline care plan included information on adjustment issues, risk factors, and therapy needs, but omitted any reference to PTSD or trauma-informed interventions. Staff interviews revealed that a trauma assessment was not completed within the required timeframe after admission, and as a result, trauma care was not included in the resident's baseline care plan. The facility's own policies required trauma-informed, person-centered care planning, but these were not followed for the residents reviewed.
Plan Of Correction
All residents have the ability to be affected. Social Services and all staff educated by DON on Trauma-Informed Care 5/22/25. PCC Trauma-Informed Care assessment put in place and completed by social services on 5/22/25 for #25, #140, and on all appropriate residents. DON/designee to audit trauma-informed assessments on new admissions weekly for 4 weeks. Results to be reviewed in QAPI.