Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify and address a resident's history of trauma and associated triggers, resulting in a lack of trauma-informed and culturally competent care. The resident had a documented diagnosis of chronic post-traumatic stress disorder (PTSD), with provider notes indicating ongoing treatment and medication adjustments for PTSD and depression. Interviews revealed the resident had a significant trauma history, including an abusive marriage, the loss of a child, and childhood hospitalization. Staff acknowledged that the resident experienced triggers, such as believing her ex-husband was present at the facility, but there was no recent discussion of her PTSD diagnosis among staff due to staff turnover. Review of the resident's care plan showed it did not include the PTSD diagnosis, nor did it identify specific triggers or interventions to prevent re-traumatization. The resident's Minimum Data Set (MDS) assessment did not indicate PTSD as an active diagnosis, and no trauma-informed care assessment or social history was provided upon request. Staff interviews confirmed there was no process to ensure communication of specialized provider diagnoses to staff, contributing to the lack of trauma-informed care planning for the resident.