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 care plan to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who was admitted with diagnoses including metabolic encephalopathy, major depressive disorder, and PTSD, did not have their PTSD triggers identified in the care plan. Additionally, there were no resident-specific interventions documented to minimize triggers or prevent re-traumatization related to the PTSD diagnosis. A review of the resident's clinical record and staff interviews confirmed that the care plan in effect at the time of review did not address the resident's PTSD needs according to professional standards of practice. The Nursing Home Administrator was unable to demonstrate that culturally competent, trauma-informed care was provided, or that the resident's experiences and preferences were considered to eliminate or mitigate potential triggers for re-traumatization.