Failure to Provide Trauma-Informed Care and Timely Behavioral Health Referrals for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for residents diagnosed with Post Traumatic Stress Disorder (PTSD), as evidenced by multiple missed opportunities to assess, refer, and address the mental health needs of two residents. One resident had a documented history of suicidal ideation, hallucinations, and an active diagnosis of PTSD, yet there was no evidence of timely referrals for behavioral health services, counseling, or follow-up with external providers such as Acadia or the VA. Despite repeated episodes of suicidal speech and behavior, as well as recommendations for mental health counseling, the facility did not initiate appropriate referrals or interventions from admission through several months of the resident's stay. Clinical documentation revealed that the resident experienced severe psychiatric symptoms, including visual hallucinations and multiple expressions of suicidal intent, but the facility's response was limited to medication administration and basic medical workup. There was no documentation that the resident's PTSD was addressed during these episodes, nor that a trauma-informed assessment was completed. The Pre-admission Screening and Resident Review (PASRR) also indicated a need for individual therapy, but no evidence was found that the facility made the required referrals until several months later. A second resident with an active PTSD diagnosis also did not receive a trauma-informed care plan that identified or addressed their specific triggers. The social services staff confirmed that trauma assessments were not completed based on the resident's current diagnosis, and the care plan lacked individualized interventions related to PTSD. The facility's own policy required in-depth assessment and care planning to minimize re-traumatization, but these steps were not followed for either resident.