Failure to Assess and Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and implement trauma-informed care for a resident with a known history of post-traumatic stress disorder (PTSD) and past traumatic experiences. The resident, who had intact cognition and required assistance with all activities of daily living, reported a long history of verbal, physical, and sexual abuse, and continued to experience distressing symptoms such as seeing demon-like shadows and feeling triggered by staff interactions. Despite the resident's disclosure of PTSD and ongoing trauma-related symptoms, there was no evidence in the electronic health record (EHR) of a trauma assessment being completed, nor were individualized trauma-informed interventions or identification of triggers included in the care plan. Interviews with facility staff, including nursing assistants, registered nurses, the clinical coordinator, and the social worker, revealed that none were aware of the resident's PTSD diagnosis or specific triggers. The social worker and assistant director of nursing confirmed that a trauma assessment had not been completed and the PTSD diagnosis was not documented in the EHR or care plan. The facility's own policy required trauma-informed care assessments upon admission and as needed, with care plans reflecting identified triggers and interventions, but this was not followed for the resident in question.