Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to four residents diagnosed with Post Traumatic Stress Disorder (PTSD). Review of the residents' clinical records and care plans revealed that the facility did not identify or address individual trauma triggers for these residents. Specifically, the care plans for each resident with a PTSD diagnosis did not include information on their specific triggers or strategies to avoid them. In one case, a resident's care plan included general interventions such as asking about trauma and involving the social worker, but still failed to identify individualized triggers. Additionally, inconsistencies were found in the documentation, such as a social service assessment indicating no history of PTSD despite other records confirming the diagnosis. Interviews with the Director of Social Services confirmed that the process for identifying trauma history and triggers was not consistently followed, resulting in the lack of individualized care planning for trauma survivors. The deficiency was identified for all four residents reviewed, each with a documented history of PTSD and other medical conditions such as high blood pressure, chronic pain, depression, anxiety, and anoxic brain injury. The failure to provide trauma-informed care was confirmed by facility staff and supported by the review of clinical records and care plans.