Failure to Provide Trauma-Informed, Person-Centered Care for Resident with PTSD and History of Sexual Assault
Penalty
Summary
A resident with a documented history of multiple traumas, including sexual assault and combat-related experiences, was admitted with diagnoses of PTSD, major depressive disorder, anxiety disorder, and dementia. The resident's social history and assessment tools clearly indicated significant trauma history, yet the facility failed to develop an individualized, person-centered care plan addressing known triggers and specific interventions related to the resident's PTSD and trauma. The care plan only included a general intervention for female caregivers and did not incorporate detailed information from the resident's social history or trauma assessments. The facility did not have a policy or procedure for trauma-informed care and did not ensure that non-pharmacological interventions were documented or implemented when the resident exhibited targeted behaviors such as behavioral disturbances, crying, restlessness, or anxiety. Staff interviews revealed a lack of awareness regarding the resident's specific triggers, and the social worker had not obtained previous mental health records or communicated critical incident information to the psychiatric nurse practitioner. The facility also failed to involve the psychiatric provider in developing a person-centered care plan after a significant incident. An incident occurred in which another resident made unwanted sexual contact with the resident who had a history of sexual trauma. The facility's response was delayed in moving the offending resident, and staff were aware of ongoing inappropriate behavior but did not implement adequate protective measures. The care plan was only updated after the incident, and there was no evidence of a thorough assessment or individualized interventions to address the resident's trauma-related needs. The facility did not provide appropriate treatment and services to help the resident attain the highest practicable mental and psychosocial well-being.