Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to implement trauma-informed care for two residents diagnosed with post-traumatic stress disorder (PTSD). One resident had a history of childhood molestation and was identified as having severe cognitive impairment, depression, anxiety, and PTSD. Despite documentation of her trauma history and potential triggers, her care plan was not updated to address current PTSD-related symptoms or triggers. When this resident reported feeling unsafe due to harassment and sexual advances from another resident, the facility's response was limited to offering an alternative smoking area and notifying law enforcement, without comprehensive assessment or ongoing monitoring for psychosocial harm or exacerbation of PTSD symptoms. The second resident, also with a history of childhood sexual abuse and other mental health diagnoses, exhibited behaviors such as writing sexual notes and following female residents, including the first resident, to unsupervised areas. Although his care plan noted a preference for female caregivers and a history of trauma, it did not address his sexual behaviors toward others or include updated interventions. Reports from multiple residents about his inappropriate behavior were met with education for the resident, but there was no evidence of behavior management, supervision, or monitoring to mitigate the risk of re-triggering PTSD in other residents. Interviews with the affected resident and her family revealed ongoing distress, including increased PTSD symptoms, trouble sleeping, and feelings of being unsafe, despite repeated reports to staff. The facility's trauma-informed care policy required identification of triggers, individualized interventions, and ongoing evaluation with resident and family input, but these steps were not followed. The lack of comprehensive assessment, care plan updates, and effective interventions contributed to the deficiency in providing trauma-informed care.