Failure to Provide Trauma-Informed Care and Assessment
Penalty
Summary
The facility failed to evaluate and implement interventions to manage trauma triggers for a resident with a self-reported diagnosis of Post Traumatic Stress Disorder (PTSD). Record review showed that the resident had a history of PTSD related to previous domestic abuse, as well as other diagnoses including stroke, hypertension, diabetes mellitus, anxiety disorder, and bipolar disorder. The resident reported specific triggers, such as not liking water poured over the face due to past abuse, and had a history of substance use, homelessness, and legal issues. Despite this, the resident's care plan did not include any focus area related to anxiety, depression, mood, or past traumatic event triggers. Interviews and record reviews confirmed that the facility had not completed a trauma-based assessment or initiated a trauma-informed care plan upon the resident's admission, as required by facility policy. The facility's policy mandates culturally competent and trauma-informed care, including minimizing triggers and re-traumatization for trauma survivors. However, the lack of assessment and care planning for the resident's trauma history and triggers constituted a failure to provide care and services in accordance with these standards.