Failure to Include Trauma-Informed Interventions in Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to ensure that care plans included trauma-informed interventions for a resident diagnosed with PTSD. The resident, who is cognitively intact and has a history of trauma from both sexual abuse and war zone service, was screened for PTSD and found to have some symptoms. Despite this, the resident's care plan did not identify any specific triggers related to PTSD, and the resident reported not discussing these triggers with the social worker. The absence of identified triggers in the care plan was confirmed by both the social worker and through record review. Additionally, the facility did not have a specific trauma-informed care policy in place. The administrator acknowledged that there was no dedicated trauma-informed policy, and the existing person-centered care plan policy only briefly mentioned that care plans should be trauma-informed and culturally competent, without providing further guidance on identifying or addressing trauma triggers. This lack of detailed policy and omission of PTSD triggers in the care plan contributed to the deficiency.