Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
A resident with a medical diagnosis of post-traumatic stress disorder (PTSD) was not provided with appropriate treatment and services to support his highest practicable mental well-being. The resident, a former prisoner of war, reported frequent nightmares, distressing memories, and avoidance of activities that reminded him of past trauma. He also described a history of violent dreams that affected his relationship with his wife, who no longer felt safe staying overnight with him. Despite these ongoing symptoms and an increase in the frequency of distress as indicated by recent trauma assessments, the resident had never been referred to or seen by a psychiatrist or psychologist for his PTSD. Review of the resident's care plan revealed that there was no focus, goal, or interventions addressing PTSD or trauma, nor were there strategies for staff to identify triggers or assist the resident if triggered. Previous trauma assessments showed a recent increase in the severity of symptoms, but this was not reflected in the care planning. The facility's own policy on trauma-informed care requires services that address the needs of trauma survivors, but this was not implemented for the resident in question.