Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD), dysphagia, and anxiety. The resident's record showed that, despite having physician orders for anxiety medications, there was no Trauma Informed Care Evaluation completed to identify and address the resident's trauma-related needs. Additionally, the care plan for PTSD was not completed in a timely manner. This was confirmed during an interview with the facility's social worker, who acknowledged the absence of the required evaluation and the delay in care plan completion. These findings demonstrate that the facility did not take necessary steps to eliminate or mitigate triggers that could cause re-traumatization for the resident, as required by regulatory standards.