Failure to Provide Trauma-Informed, Culturally Competent Care for a Resident With PTSD
Penalty
Summary
The facility failed to provide trauma-informed, culturally competent care to a resident with known trauma history and PTSD. Facility policy on Trauma Informed Care and Culturally Competent Care, revised April 22, 2025, stated that assessment should involve an in-depth evaluation of symptoms, their relationship to trauma, and identification of triggers to minimize or prevent re-traumatization. Clinical record review for Resident 10 showed diagnoses including post-traumatic stress disorder (PTSD) and major depressive disorder. During an interview, the resident disclosed having suffered sexual abuse as a young child. However, the admission social service evaluation dated December 23, 2025, documented in the psychosocial evaluation section that the resident did not have a diagnosis of PTSD. Further review of the resident’s comprehensive care plan did not reveal any focus area or interventions addressing PTSD or trauma. The clinical record also lacked evidence that any additional trauma screening had been completed. The facility was unable to provide documentation indicating that the resident had received trauma-informed care in accordance with its policy and professional standards of practice. In an interview, the Nursing Home Administrator and DON stated that it was the facility’s expectation that residents receive trauma-informed care, but no supporting documentation was available for this resident.
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