Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to one of three sampled residents diagnosed with post-traumatic stress disorder (PTSD). The resident, who also had diagnoses of depressive disorder, diabetes mellitus, and dementia, was moderately impaired in cognitive skills and required varying levels of assistance with daily activities. Despite documentation in the resident's records indicating a diagnosis of PTSD, staff interviews revealed that the registered nurse was unaware of the resident's PTSD diagnosis and that no specific trauma-informed care or services were provided for residents with PTSD. Further review of facility policies showed that there were procedures in place for the care of residents with PTSD and for trauma-informed care, which included assessing behavioral health history and ensuring person-centered care to avoid re-traumatization. However, these policies were not implemented for the resident in question, as evidenced by the lack of staff awareness and absence of trauma-informed interventions. This deficiency was identified through interviews and record reviews, highlighting a failure to follow established protocols for residents with a history of trauma.