Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
Facility staff failed to provide appropriate trauma-informed care for one resident diagnosed with post-traumatic stress disorder (PTSD), among other medical and psychiatric conditions. The resident was cognitively intact and had a documented history of PTSD, anxiety, depression, and hallucinations. Despite this, the clinical record lacked any trauma-informed care assessments, and the comprehensive person-centered care plan did not identify or address specific triggers related to the resident's PTSD. Psychiatry progress notes indicated ongoing symptoms and identified nightmares and hallucinations as potential triggers, but these were not incorporated into the care plan interventions. Interviews with facility staff and administration revealed that the interdisciplinary team did not discuss or address the resident's PTSD during care plan meetings, and staff were not adequately educated on trauma-informed care. The facility's own policy required trauma assessment and identification of triggers, but these steps were not followed for the resident in question. The deficiency was confirmed through staff interviews, clinical record review, and facility document review, with no further relevant information provided to the survey team prior to exit.