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 PTSD. Upon review, it was found that the resident, who has a history of paraplegia, anxiety disorder, PTSD, and recurrent depressive disorders, did not have a complete trauma assessment or a care plan addressing their PTSD diagnosis, triggers, or specific interventions. The resident's most recent MDS indicated cognitive intactness and some social isolation, but the care plan lacked any reference to PTSD or trauma-related needs. Further investigation revealed that the trauma history evaluation for the resident was only partially completed, with only two out of six sections fully filled out. During an interview, the facility's social worker confirmed that the process for residents with PTSD should include a complete trauma assessment and a care plan addressing trauma, triggers, and interventions. However, the social worker acknowledged that these steps were not completed for this resident, resulting in a deficiency in providing care that is trauma-informed and culturally competent as required by facility policy.