Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify trauma-based triggers and implement individualized interventions for a resident with a diagnosis of post-traumatic stress disorder (PTSD). The resident's electronic medical record documented multiple mental health diagnoses, including PTSD, panic disorder, major depressive disorder, anxiety, and bipolar disorder, with a Brief Interview of Mental Status (BIMS) score indicating intact cognition. Despite these diagnoses, the resident's care plan did not include any direction or interventions specific to PTSD, and the trauma-informed care assessment was missing from the resident's record. The Psychotropic Drug Use Care Area Assessment also lacked analysis related to trauma-informed care. Interviews with facility staff confirmed that the social services department was responsible for completing trauma-informed care assessments and that residents with PTSD should have care plans to prevent re-traumatization. However, the care plan for this resident only noted a favorite activity and did not address past trauma or provide personalized interventions. The facility's own policy required culturally competent, trauma-informed care that minimized triggers and re-traumatization, but this was not reflected in the resident's documentation or care planning.
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