Failure to Provide Trauma-Informed, Person-Centered Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a documented history of PTSD, anxiety, altered mental status with auditory hallucinations, and a history of sexual and physical trauma. The resident's PASRR Level I screening indicated serious mental illness, but required sections were left incomplete and there was no documentation of further assessment. A subsequent mental illness screening confirmed the need for specialized services, yet the necessary follow-up and documentation were not completed within the required timeframe. The resident's care plan acknowledged PTSD but did not document the trauma history or identify individual triggers, and interventions were limited to a psychiatric consult without person-centered details. The MDS and CAAs did not reference trauma-informed care planning, and the psychosocial evaluation failed to incorporate the resident's trauma history or PTSD-related concerns. Staff interviews revealed that the resident frequently referenced past traumas during personal care and exhibited behaviors consistent with re-experiencing traumatic events, such as mistrust, verbal aggression, and distress triggered by loud noises or unfamiliar staff. Staff acknowledged the lack of appropriate follow-up on the PASRR and incomplete documentation, as well as the absence of identified triggers and person-centered interventions in the care plan. The failure to incorporate trauma-informed, person-centered care planning placed the resident at risk for unmet psychosocial needs and a potential decline in quality of life.