Failure to Develop Trauma-Informed Care Plans for Residents with PTSD
Penalty
Summary
The facility failed to develop trauma-informed, person-centered care plans for two residents with documented histories of post-traumatic stress disorder (PTSD) and significant trauma. For one resident with schizophrenia, intellectual disability, and PTSD, the care plan did not identify or address trauma history, triggers, or interventions to minimize re-traumatization, despite hospital records indicating a history of abuse, family violence, and sexual assault. The Trauma Informed Care Assessment for this resident also failed to document any trauma, and both the Social Worker and Director of Nurses acknowledged that a care plan addressing these issues should have been in place. For another resident with anxiety, depression, bipolar disorder, and PTSD, the care plan did not address the resident's PTSD, history of suicide attempt, or identify triggers that could lead to re-traumatization. Medical records from a previous facility documented a suicide attempt and ongoing psychiatric care, but the Trauma Informed Care Assessment did not reflect this history. Staff interviews confirmed that the care plan should have included interventions for PTSD and suicide risk, but these were not present.