Failure to Provide Trauma-Informed Care for Trauma Survivors
Penalty
Summary
The facility failed to provide trauma-informed care for two residents identified as trauma survivors, including one resident with a diagnosis of PTSD. Clinical record review showed that the care plan for this resident did not address their trauma history, PTSD, or specific triggers and interventions, despite documentation of related diagnoses and symptoms. The care plan only included general interventions for depression and anxiety, omitting trauma-specific needs. Staff interviews revealed a lack of awareness among nursing, activity, and social work staff regarding the resident's trauma history, with several staff members unaware of the PTSD diagnosis or the need for trauma-informed interventions. The resident reported not being invited to care plan meetings and described ongoing PTSD symptoms, including nightmares and withdrawal when triggered. The Assistant Director of Nursing acknowledged not realizing the resident was a trauma survivor until recently, and the acting social worker was also unaware of the resident's trauma history, despite being responsible for assessments. The Advanced Registered Nurse Practitioner confirmed that PTSD was the main mental health issue for the resident. These findings indicate that the facility did not ensure trauma-informed care planning or staff awareness for residents with a history of trauma.