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F0699
D

Failure to Provide Trauma-Informed Care for Resident with PTSD

Pasadena, California Survey Completed on 06-05-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD) and major depressive disorder. The resident's admission record and social service assessment documented PTSD with specific triggers, including being touched, loud noises, and yelling. Despite this, the resident reported never having a care plan discussion regarding PTSD, and staff interviews revealed a lack of awareness about the resident's diagnosis and triggers. The resident also stated that loud music played in the hallway triggered her PTSD and caused migraine headaches, and she was told by a social worker to keep her door open during these activities, despite her discomfort. Observations confirmed that loud music was played daily in the hallway as part of a facility activity, which the resident identified as a trigger. Staff members, including a CNA and LVN, were unaware of the resident's PTSD or had not received training on trauma-informed care or PTSD. The Director of Nursing confirmed that no comprehensive care plan addressing the resident's PTSD and its triggers had been developed, and acknowledged that the daily activity could trigger the resident's symptoms. A review of the facility's policy on trauma-informed care indicated that staff should identify triggers and implement adjustments to reduce trauma-related distress, and that training should be provided to employees. However, the policy was not followed, as staff had not received the required training and no trauma-informed care plan was in place for the resident, resulting in ongoing exposure to known PTSD triggers.

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