Failure to Provide Trauma-Informed, Culturally Competent Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of PTSD received trauma-informed and culturally competent care in accordance with professional standards. Upon admission, no trauma screening was completed to identify possible triggers, despite the resident's documented history of PTSD. The initial social service history assessment lacked screening questions related to trauma, and the 'Make Me Feel Important' form, intended to identify specific triggers and de-escalation interventions, was not filled out for the resident. Interviews with facility staff, including the Social Services Director and Administrator, confirmed that trauma screening was not part of the admission process and that staff were unaware of the omission. The resident's care plan noted a history of being fearful and easily annoyed due to PTSD, with a goal to manage symptoms and avoid fearful episodes. However, there was no evidence of trauma-specific services or interventions being provided. The facility's policy required a trauma screening tool to be implemented as part of the admissions process, but this was not followed. Staff interviews revealed a lack of awareness and implementation of trauma-informed care practices, and the necessary documentation to identify and mitigate potential triggers for the resident was incomplete or missing.