Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents with a diagnosis of post-traumatic stress disorder (PTSD). Facility policy requires the identification of triggers that may re-traumatize residents with a history of trauma. However, a review of the clinical record for one resident revealed the absence of a PTSD care plan with identified triggers, despite documentation of agitation, yelling profanities, and aggressive behavior. The resident's diagnoses of PTSD, depression, and insomnia were current at the time of review. Similarly, another resident with a diagnosis of PTSD did not have a care plan developed with goals and interventions related to PTSD. The care plan review did not include any trauma-informed strategies or identification of triggers. During staff interviews, it was confirmed that the facility failed to provide trauma-informed care to eliminate or mitigate triggers that could cause re-traumatization for both residents.