Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a diagnosis of PTSD. Upon admission, the resident was cognitively intact and able to communicate effectively. The facility's policy required staff to identify and minimize trauma triggers, but the resident's trauma history was not addressed in the care plan, and there was no evidence that family members were interviewed to identify potential triggers. The resident declined to complete the trauma assessment, but there was no further follow-up or individualized care planning related to trauma history or triggers. An incident occurred in which an LPN smelled the resident's hair, pushed the resident's wheelchair into their room, and hugged and rubbed the resident's arms, actions that the resident reported as triggering their PTSD. The LPN was aware of the resident's PTSD diagnosis from both the medical record and conversations with the resident. Despite this, no interventions or care plan elements were implemented to address the resident's trauma triggers. Facility leadership acknowledged that nothing had been implemented regarding the resident's trauma history or triggers.