Failure to Follow Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to follow care planned interventions to prevent re-traumatization for a resident diagnosed with post-traumatic stress disorder (PTSD) and a history of sexual abuse. The resident's care plan and trauma history assessment clearly indicated a preference for female caregivers and an inability to tolerate male staff in his room, due to past trauma involving male perpetrators. Despite these documented interventions, male staff continued to enter the resident's room alone, including an observed incident where a male staff member entered with a lunch tray and closed the door. The resident reported ongoing distress and anger related to these incidents, stating he did not feel safe and that his PTSD was not being taken seriously by staff. Interviews with facility staff revealed a lack of awareness regarding the resident's preference for female caregivers, with several staff members and a registered nurse referencing care sheets and stating that only one other resident (not the resident in question) had such a preference. The care sheets and aide care plan lacked information about the resident's need for female-only caregivers, despite this being documented in the care plan. The nurse manager confirmed that staff should have been aware of and following the resident's preferences. Additionally, the facility was unable to provide a policy on behavioral management and trauma informed care when requested.