Failure to Provide Trauma-Informed, Culturally Competent Care for Residents with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care in accordance with professional standards of practice for two residents diagnosed with PTSD. Review of the clinical records for both residents revealed that there was no documented evidence of an assessment related to PTSD being conducted. Additionally, there was no documentation indicating that either resident received services to address their PTSD diagnoses. The facility's policy requires universal screening and assessment for trauma, as well as individualized care planning to address trauma-related needs, but these steps were not followed for the residents in question. Further review showed that for one resident, a psychiatric evaluation was performed, but the PTSD diagnosis was not mentioned or addressed in the evaluation. Neither resident had a care plan that addressed their PTSD diagnosis, despite this being a requirement under the facility's trauma-informed care policy. These omissions indicate that the facility did not account for the residents' past experiences and preferences, nor did it take steps to eliminate or mitigate potential triggers that could cause re-traumatization.