Failure to Provide Trauma-Informed Care for Resident with PTSD and Dementia
Penalty
Summary
The facility failed to provide trauma-informed care to a resident with a history of dementia, major depressive disorder, anxiety disorder, intermittent explosive disorder, alcohol abuse, and post-traumatic stress disorder (PTSD). The resident had documented traumatic experiences, including being assaulted and serving in the Vietnam War, which were noted in psychosocial assessments and family interviews. Despite these documented traumas and ongoing behavioral symptoms such as paranoia, hallucinations, resistance to care, and combativeness, there was no evidence that trauma-specific assessments were completed after admission. The resident's care plan, last reviewed in April 2025, did not reference trauma, trauma triggers, or trauma-informed interventions, even though the resident was dependent on staff for emotional, intellectual, physical, and social needs due to cognitive deficits. The Kardex for nursing assistants and nursing progress notes from June 2024 to June 2025 also lacked any information or documentation relevant to trauma or trauma-informed care. Staff interviews confirmed a lack of knowledge regarding specific trauma-related care or triggers for the resident, and the social services staff reported that no specific trauma assessment was used beyond an initial screening at admission. The facility's policy required assessment and care planning for trauma and behavioral health issues on admission and quarterly, including identification of triggers and non-pharmacological interventions. However, the care plan and supporting documentation did not reflect these requirements for the resident in question, and staff were not able to identify or implement trauma-informed care practices as outlined in the policy.