Failure to Provide Trauma-Informed, Culturally Competent Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident's care plan was not person-centered and did not specify the nature of the trauma, the resident's triggers, or individualized interventions. Although the facility's policy required a multi-pronged approach to identifying trauma history and developing individualized care plans in collaboration with the resident and relevant professionals, these steps were not adequately implemented for this resident. Documentation and interviews revealed that the resident had a history of PTSD, bipolar disorder, anxiety, depressive disorder, and dementia, and was cognitively intact. The care plan and related documents lacked specific information about the traumatic events, the resident's triggers, and appropriate interventions. Staff, including CNAs, the RN/Unit Manager, and the Social Service Director, were unable to articulate what the resident's trauma was, what might trigger the resident, or what specific actions should be taken to prevent re-traumatization. The psychologist's notes referenced the PTSD diagnosis and the intention to use trauma-informed approaches, but there was no evidence of direct communication or collaboration with the facility staff regarding individualized interventions. The resident's care documentation was updated only after surveyor inquiry, and prior to this, the care plan and bedside Kardex did not include trauma-specific information. Staff interviews indicated a lack of awareness and understanding of the resident's PTSD, triggers, and appropriate responses. There was also no evidence of interdisciplinary collaboration with the psychologist or use of their expertise to inform care planning. As a result, the facility did not ensure that the resident received trauma-informed, culturally competent care in accordance with professional standards and the facility's own policies.