Failure to Provide Trauma-Informed, Culturally Competent Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident with a documented history of schizophrenia, epilepsy, and post-traumatic stress disorder (PTSD). Clinical records indicated that the resident had experienced sexual abuse and violence in the past, including while incarcerated, and expressed ongoing feelings of not being safe. Despite this information being documented in progress and psychology notes, the care plan did not identify specific trauma triggers or interventions tailored to the resident's needs. Further review showed that the care plan only generally referenced the potential for behaviors resulting from past trauma but did not include individualized strategies to mitigate or prevent re-traumatization. Interviews with the DON and Facility Administrator confirmed that the facility did not adequately identify the resident's past traumatic experiences or possible triggers that could lead to re-traumatization, as required by professional standards and regulations.