Failure to Assess and Address PTSD and Trauma-Informed Care Needs
Penalty
Summary
The facility failed to identify, assess, and document the trauma-related history and PTSD diagnosis for a resident with a known history of military trauma and PTSD. Despite the resident's documented diagnosis of PTSD and anxiety, and a history of serving in Vietnam, the facility did not complete a trauma assessment or evaluate the resident's PTSD. The care plan did not include any triggers or interventions related to managing PTSD, and staff interviews revealed a lack of awareness and understanding of the resident's trauma history and related needs. The facility also lacked a system or process for completing trauma assessments for residents with known trauma histories. Observations and interviews indicated that the resident expressed a preference for being outdoors and discomfort when confined indoors, which was not reflected in the care plan or communicated to all staff. Social services and nursing staff confirmed that there was no screening process for PTSD on admission, and that the care plan did not address trauma-related triggers or interventions. The facility did not have a policy or procedure specific to trauma-informed care, and staff were not consistently aware of the resident's PTSD diagnosis or how to address it in care planning.