Failure to Provide Trauma-Informed and Culturally Competent Care for Residents with PTSD
Penalty
Summary
The facility failed to implement trauma-informed and culturally competent care approaches for two residents with diagnosed post-traumatic stress disorder (PTSD) and histories of trauma. Both residents, who were veterans, had intact cognition and multiple mental health diagnoses, including PTSD, depression, and anxiety. Despite these diagnoses, neither resident had individualized care plan interventions that addressed their trauma histories, potential triggers, or specific behavioral symptoms related to PTSD. One resident reported not having discussed her past traumas with staff and did not recall being offered counseling services since admission, while the other resident was unaware that the facility recognized his PTSD diagnosis and had not been offered related services. Review of the residents' electronic medical records and care plans revealed that the interventions listed were generic and did not include trauma-specific strategies, identification of triggers, or guidance for staff on monitoring and responding to PTSD-related behaviors. The care plans lacked person-centered approaches tailored to the residents' unique trauma experiences, as required by facility policy. Additionally, the trauma screening and social services assessments were incomplete or inaccurately documented, with key questions about trauma history and mental health diagnoses marked as "No" despite clear evidence to the contrary in the residents' medical records. Interviews with facility staff, including the social services designee and the director of nursing, confirmed that trauma-informed care was not addressed in the care plans for these residents. Staff acknowledged that information gathered during trauma assessments should be included in care plans to prevent re-traumatization and to guide individualized care. The facility's own policy emphasized the need for person-centered care planning and consistent implementation of care approaches for residents with trauma histories, but these requirements were not met for the two residents in question.