Failure to Provide Trauma-Informed and Culturally Competent Care
Penalty
Summary
The facility failed to develop and implement clinically appropriate, person-centered care approaches for a resident with a history of personal trauma and substance abuse. The resident's electronic health record documented diagnoses of major depressive disorder, anxiety, and PTSD, as well as a history of illicit drug use. Despite these documented conditions, the resident's care plan did not address identified triggers, adjustment difficulties, or provide interventions related to trauma or substance abuse history. The care plan also lacked descriptions of the resident's indications of distress and did not include strategies to assist the resident. Progress notes over several months did not document the resident's past trauma, and the facility's assessment listed zero residents with active or current substance use disorders, despite evidence to the contrary in the resident's records. Interviews with facility staff revealed a lack of recognition and documentation of the resident's PTSD and substance abuse history. Social services staff denied the presence of PTSD and substance abuse among residents, contradicting the medical records. Administrative staff indicated that PTSD diagnoses should be coordinated and incorporated into care plans through interdisciplinary meetings, but this was not reflected in the resident's care plan or facility documentation. Additionally, the facility was unable to provide a policy on trauma-informed care.