Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comprehensively assess and implement individualized trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who had a history of depression, schizophrenia, and PTSD related to religious persecution, starvation, and violence in Sudan, was not provided with a care plan that identified specific trauma triggers or individualized interventions. The Care Area Assessment Summary for psychosocial well-being was not completed, and the care plan only generically referenced the PTSD diagnosis without detailing the nature of the trauma or strategies to avoid re-traumatization. Interviews with facility staff, including a nursing assistant and a registered nurse, revealed a lack of awareness regarding the resident's PTSD diagnosis, history, and appropriate trauma-informed interventions. The assistant director of nursing confirmed that while the care plan included general interventions such as referrals to psychiatric services and encouragement of trauma-informed care, it did not specify resident-specific details or triggers. Facility policy required that care plans for residents with a history of trauma include goals and interventions to address potential triggers, which was not followed in this case.