Failure to Provide Trauma-Informed, Individualized Care for Resident with PTSD
Penalty
Summary
The facility failed to identify trauma-based triggers and implement individualized interventions for a resident diagnosed with post-traumatic stress disorder (PTSD), bipolar disorder, and schizoaffective disorder. The resident's care plan included general monitoring for hallucinations and adverse medication side effects, as well as providing opportunities for the resident to talk about feelings when upset. However, the care plan did not include personalized interventions specifically addressing the resident's PTSD or strategies to prevent re-traumatization, despite documentation in the medical record and assessments indicating the resident experienced nightmares and avoided situations that reminded her of past trauma. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for completing PTSD assessments and updating care plans with trauma-specific information. Staff members were unsure who was responsible for ensuring that the type of trauma and individualized interventions were included in the care plan. The facility's policy required trauma-informed care and screening for trauma experiences, but this was not consistently implemented for the resident in question.