Failure to Provide Trauma-Informed, Person-Centered Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered plan to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). A review of the facility's policy on trauma-informed care indicated that care and services should be culturally competent, account for resident experiences and preferences, and address the needs of trauma survivors by minimizing triggers and re-traumatization. However, the clinical record for the resident, who was admitted with diagnoses including PTSD and anxiety, did not include identification of PTSD symptoms, triggers, or resident-specific interventions to address these needs. Additionally, an outside psychiatry consultation for the resident did not mention a history of PTSD, and the current care plan in effect at the time of review failed to address the resident's PTSD diagnosis or provide interventions to minimize triggers and re-traumatization. Interviews with the Nursing Home Administrator and Social Services Director confirmed that the facility could not demonstrate the provision of culturally competent, trauma-informed care in accordance with professional standards and the resident's preferences.
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