Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for one resident diagnosed with Post Traumatic Stress Disorder (PTSD) among a sample of 24 residents. The resident had a history of traumatic brain injury, repeated falls, seizures, and PTSD, with documented triggers including feeling belittled due to a history of abusive relationships and anxiety related to car rides following multiple car accidents. The care plan identified these triggers and the need to minimize exposure to them. However, interviews with staff revealed that direct care staff, including a CNA and a charge nurse, were unaware of the resident's PTSD diagnosis, her specific triggers, or the location of the PTSD care plan binder. The medication nurse was aware of the PTSD diagnosis but did not know the resident's specific triggers. The Social Service Director confirmed knowledge of the resident's PTSD and triggers and stated that this information was available in a PTSD binder on the unit, which staff were expected to review. Despite this, the Director of Staff Development acknowledged that there were no scheduled in-services on PTSD for the year, and several staff members were unaware of the PTSD binder or the expectation to review it. The Director of Nursing stated that staff should be familiar with residents' PTSD history and triggers and that this information should be care planned and accessible. Facility policy required assessment and care planning to minimize exposure to trauma triggers, but staff interviews and record review demonstrated that this was not consistently implemented.