Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with dementia, anxiety disorder, and post-traumatic stress disorder (PTSD). The resident, who had moderately impaired cognition as indicated by a BIMS score of 10/15, exhibited confrontational behavior and hallucinations related to war, as documented in progress notes by an LPN. Despite these symptoms and the PTSD diagnosis, there was no evidence in the medical record that a trauma-informed care assessment had been completed for the resident. Further review and interviews revealed that the resident's care plan did not address the PTSD diagnosis, and no assessment had been conducted to identify potential triggers that could cause re-traumatization. The facility's own policy required the use of a multi-pronged approach to identify trauma history and triggers, as well as collaboration with the resident and relevant professionals to develop individualized care plan interventions. These steps were not followed for the resident in question.