Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a documented history of post-traumatic stress disorder (PTSD) and childhood abuse. The resident was admitted with multiple diagnoses, including PTSD, and her medical record indicated ongoing symptoms such as nightmares, flashbacks, and hypervigilance, particularly at night. Despite these documented issues, the electronic medical record did not include a care plan specifically addressing her trauma history or PTSD, and psychosocial assessments inaccurately stated that she had never been diagnosed with PTSD or experienced a life-altering event. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's trauma history and specific triggers. While some staff were aware of the PTSD diagnosis, there was no written documentation or care plan to guide staff in providing trauma-informed care or to ensure that interventions, such as assigning only female CNAs, were consistently implemented. The Social Services staff were either unaware of the PTSD diagnosis or not informed of the details, and acknowledged that the psychosocial assessments were inaccurate and that no trauma-informed care plan had been developed or implemented. The facility's own policy required the development of a comprehensive, person-centered care plan for residents with trauma histories, including identification of triggers and appropriate interventions. However, this was not done for the resident in question, and staff were not provided with the necessary information to avoid retraumatization. The deficiency was identified through observation, interview, and record review, confirming that the facility did not meet its own standards or regulatory requirements for trauma-informed care.