Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma and a diagnosis of PTSD received trauma-informed, culturally competent care in accordance with professional standards. The resident's care plan did not include specific triggers related to his PTSD, despite documentation in his trauma assessment and direct communication from the resident about his triggers, which included loud noises, war pictures, and water. Staff interviews revealed that direct care staff, including a CNA and an LVN, were either unaware of the resident's PTSD diagnosis or did not know his specific triggers. The care plan only generally referenced the risk of the resident being startled, without specifying the known triggers. Further, the social worker and MDS coordinator acknowledged that the resident's triggers were not included in the care plan, and the social worker confirmed that this information should have been documented to inform staff. The DON and administrator both stated that the care plan should reflect the trauma assessment and include specific triggers so staff could provide appropriate care. At the time of the survey, the facility did not have a policy on trauma-informed care, and there was no evidence that staff had been formally in-serviced on the resident's specific triggers.