Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care that considered a resident's history and preferences, specifically for a resident diagnosed with PTSD, anxiety disorder, and depression. The medical record review showed that trauma-related assessments were either marked as not applicable or left blank, and there was no documentation in the social services progress notes addressing the resident's PTSD, its impact on daily living, or any identified triggers and interventions to prevent re-traumatization. The care plan did not include a problem or interventions specific to PTSD, and the only mention of a past traumatic event lacked details about the event, triggers, or person-centered interventions. Interviews with the resident revealed a history of physical abuse leading to PTSD, with specific emotional triggers such as being coerced, having anything wrapped around her, or feeling physically restricted. The resident reported ongoing night terrors while at the facility. Interviews with CNAs indicated a lack of awareness or understanding of the resident's PTSD diagnosis, triggers, or appropriate interventions, with some staff unaware of the diagnosis and others unable to identify or confirm trauma-related interventions. This demonstrates a failure to ensure staff were informed and prepared to provide trauma-informed care tailored to the resident's needs.