Failure to Implement Comprehensive Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to implement comprehensive trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD), developmental disabilities, anxiety, major depressive disorder, and a seizure disorder. The resident, who had a history of childhood abuse, experienced a triggering event when a certified nurse aide provided her with hot coffee, resulting in a burn to her chest. This incident caused the resident to recall past trauma and led to thoughts of self-harm, necessitating her transfer to a hospital for evaluation. Prior to this incident, the resident's trauma history and mental health needs were not adequately identified or addressed in her care plan. Trauma assessments conducted after admission did not capture her trauma history, developmental and functional background, support network, or coping mechanisms. The social services designee acknowledged that she had limited information about the resident's trauma and had not proactively sought additional psychiatric or therapeutic records, nor had she requested the resident's individual service plan from her previous community-based program. The facility's policy required a multi-pronged approach to identifying trauma history and collaboration with relevant professionals to develop individualized care plans. However, these steps were not followed, and a trauma-informed care plan was not initiated until after the burn incident. The social services designee also did not follow up with the resident's counselor regarding recommended anxiety management exercises, missing opportunities to integrate effective interventions into the resident's care.