Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma and a diagnosis of PTSD received appropriate treatment and services to attain the highest practicable psychosocial well-being. The resident, who was cognitively intact and had diagnoses including PTSD, major depressive disorder, generalized anxiety disorder, and recent bilateral above-the-knee amputations, expressed specific triggers related to their trauma history. These included a strong need to be gotten out of bed immediately upon waking, a preference for the door to be left open, and a light to be left on at night. Despite these clearly communicated needs, the resident's care plan did not include individualized interventions addressing their PTSD triggers, nor did the facility have a policy regarding PTSD or trauma-based care. Staff interactions and documentation revealed repeated instances where the resident was told by nursing staff that it might not be possible to get them up multiple times during the night, or that they would have to wait for assistance due to staffing requirements for Hoyer lift transfers. The resident frequently refused to go to bed out of fear of being left in bed and feeling trapped, which was a direct trigger for their PTSD. Staff notes and interviews indicated that the resident was often left waiting for up to ten minutes or more to be assisted out of bed, and that staff did not always communicate effectively about the wait or the process, further exacerbating the resident's distress. Some staff members did not recognize the connection between the resident's behaviors and their PTSD triggers, and there was a lack of trauma-informed care planning and staff education on the subject. Multiple interviews with staff, including CNAs, RNs, the MDS Coordinator, Social Services Designee, ADON, DON, and the Administrator, confirmed that the resident's specific PTSD triggers were not included in the care plan and that staff were not consistently aware of or responsive to these triggers. Staff acknowledged that it was inappropriate to tell a resident they could not be gotten up as often as they wished, and several staff members were unaware of the need to include trauma-informed interventions in the care plan. The facility's failure to identify, care plan, and provide services responsive to the resident's trauma history and PTSD triggers resulted in the resident experiencing repeated distress and a lack of individualized, trauma-informed care.