Failure to Develop Comprehensive Trauma-Informed Care Plan
Penalty
Summary
The facility failed to ensure that an updated and comprehensive care plan addressing trauma-informed care was in place for one resident with a history of significant trauma related to the Vietnam War. The resident experienced ongoing nightmares and unpleasant memories, and preferred isolation due to distress caused by discussions about the war. Review of the care plan revealed only general instructions regarding trauma triggers, such as noise reduction and maintaining routines, without specific focus, goals, or interventions tailored to the resident's PTSD or experiences as a prisoner of war. Interviews confirmed the resident's ongoing psychological distress and avoidance of social interaction due to his trauma history. The facility's documentation indicated that the interdisciplinary team is responsible for developing individualized care plans, but in this case, the care plan lacked detailed, measurable actions to address the resident's specific trauma-related needs.