Failure to Provide Trauma-Informed, Person-Centered Care for Resident with History of Trauma
Penalty
Summary
A deficiency occurred when a resident with a documented history of trauma and a preference for female caregivers was provided incontinence care by two male staff members, despite clear care plan interventions specifying the resident's wishes. The resident, who had severe cognitive impairment, dementia, depression, anxiety, and a history of trauma involving males, was observed on video objecting to the care, verbally refusing, and expressing distress during the incident. The care plan, which was last updated to reflect the resident's trauma history and preference for female caregivers during showers and checks/changes, was not followed during this event. Medical records and interviews confirmed that the resident's family had communicated the preference for female caregivers upon admission, and this was initially accommodated. However, after the resident was moved between floors, male caregivers resumed providing care without documented objection from the family until the incident in question. On the day of the incident, the resident was resistive to care, repeatedly said "no," and expressed that her hand was being hurt while the two male caregivers continued with incontinence care. A female RN eventually completed the care after the male staff left the room. Subsequent assessments and review of photos revealed bruising and discoloration on the resident's hands and arms, though the facility attributed some of these marks to previous lab draws and a fall. The facility's own policy required person-centered care that maximizes dignity, autonomy, and choice, but the actions taken did not align with these standards. The DON confirmed that the care plan should have been followed and that care should have been paused and resumed later if the resident refused.