Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a trauma care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD) and dementia. Despite the facility's policy requiring trauma-informed care, including the identification of triggers and the development of care plan interventions for trauma survivors, there was no care plan addressing the resident's PTSD or trauma history. The resident's assessment indicated a history of trauma, depressive and anxiety symptoms, and a referral to psychotherapy, but these findings were not incorporated into a care plan. Interviews revealed that the social worker, responsible for completing trauma assessments and developing PTSD care plans, had not completed this task for the resident due to being out sick. The administrator confirmed that residents with PTSD diagnoses are expected to have care plans addressing their trauma and triggers, but this was not done for the resident in question. The deficiency was identified through record review and staff interviews.