Failure to Provide Trauma-Informed Care and Individualized PTSD Care Planning
Penalty
Summary
The facility failed to comprehensively assess and develop individualized care plans for residents diagnosed with Post Traumatic Stress Disorder (PTSD). For multiple residents with PTSD, including those with both cognitive impairment and those who were cognitively intact, the facility did not document the causes, triggers, or ongoing effects of PTSD in their medical records. Care plans lacked specific interventions to minimize triggers or prevent re-traumatization, and there was no evidence of trauma-informed assessments being conducted. Staff interviews confirmed a lack of knowledge regarding residents' PTSD triggers and the absence of trauma-informed care planning. The Director of Nursing acknowledged that the facility relied on outside counseling services for PTSD management and did not have a process in place to obtain or integrate trauma-related information into care plans. Additionally, the facility's policy required staff training on trauma-informed care and the use of trauma screening and assessment tools, but interviews revealed that such training had not been provided. The policy also mandated the development of individualized care plans to address and decrease exposure to triggers, which was not reflected in the reviewed care plans. The deficiency affected at least three residents reviewed for PTSD, with a total of seven residents identified as having PTSD in the facility.