Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a known history of PTSD, bipolar disorder, and depression. The resident, who had recently undergone a lower leg amputation and lost their spouse, expressed feelings of depression, fear about their future, and ongoing PTSD symptoms such as flashbacks and nightmares related to their experiences in the Vietnam War. Despite these disclosures, the resident reported not having shared details of their PTSD symptoms with staff, and there was no evidence that staff had conducted a thorough assessment of the resident's trauma history or identified specific triggers. Interviews with facility staff revealed that while a general care plan for mood disorders was in place, it did not address the resident's PTSD or recent traumatic experiences, such as the amputation and loss of their spouse. The Social Services Director acknowledged awareness of the resident's PTSD diagnosis but had not developed a care plan with interventions specific to PTSD or identified triggers. Documentation showed only a brief mention of PTSD in a trauma screening questionnaire, with no further information on triggers or interventions. As a result, the resident's trauma-related needs were not adequately assessed or addressed in their care plan.