Failure to Assess and Address Trauma-Informed Care Needs for Residents with PTSD
Penalty
Summary
The provider failed to assess and address the trauma-related needs of two residents diagnosed with post-traumatic stress disorder (PTSD). Both residents had moderate cognitive impairment and complex psychiatric histories, including anxiety, depression, hallucinations, and a history of chemical dependency. Despite these diagnoses, their care plans did not include specific interventions, triggers, or behavioral supports related to their PTSD or associated mental health conditions. One resident, a military veteran, had a documented incident where he struck another resident after being disturbed in his room, yet his care plan lacked any trauma-informed strategies or behavioral interventions. Additionally, there was no evidence that either resident was receiving scheduled or as-needed mental health services as indicated in their care plans. Interviews with facility staff, including the DON and LPNs, revealed that there was no policy or formal assessment process for trauma-informed care in place. Staff acknowledged that while trauma was noted at admission, there was no documentation or follow-up assessment, and interventions for PTSD were not identified or implemented in the care plans. The facility's own policy referenced the need to identify and implement interventions for residents with trauma or psychiatric diagnoses, but this was not reflected in practice. No trauma-informed care policy was provided when requested by surveyors.