Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Summary
The facility failed to develop a person-centered plan of care for a resident with PTSD, which included identifying and mitigating trauma triggers to avoid potential re-traumatization. The facility's policy on trauma assessment and care guidelines required that trauma survivors receive culturally competent, trauma-informed care, and that care plans include trauma triggers and interventions. However, the care plans for the resident did not specify the resident's triggers, despite the resident expressing a desire to discuss their trauma and triggers during assessments. The resident, who was admitted with diagnoses including depression, anxiety, and PTSD, was moderately cognitively impaired and had a trauma-informed assessment completed. The assessment revealed that the resident had experienced childhood trauma, which still affected them, and they had a community therapist for ongoing sessions. Despite this, interviews with staff indicated a lack of awareness regarding the resident's PTSD triggers, with staff members unaware of specific triggers that should be avoided to prevent exacerbating the resident's anxiety or PTSD. The Director of Social Services acknowledged that while the resident's trauma and triggers were documented in progress notes, they were not clearly indicated in the care plans. This lack of clarity in the care plans meant that staff were not adequately informed about the resident's specific triggers, which could lead to potential re-traumatization. The care plans included general interventions for anxiety and depression but failed to address the resident's specific PTSD triggers.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident admitted with PTSD, depression, polyneuropathy, and insomnia, and assessed as having no cognitive impairment but needing substantial assistance with ADLs, was not evaluated for PTSD-related symptoms or triggers. The care plan did not address the resident’s trauma history, identify triggers, or include specific interventions to minimize triggers or re-traumatization. The DON confirmed that no PTSD assessment or related care planning had been completed, resulting in a deficiency in required nursing services.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with PTSD and major depressive disorder, and a documented history of childhood abuse, was evaluated by psychiatry, which recorded the resident’s trauma history and preference to avoid male caregivers. Facility policy required identification of trauma triggers and inclusion of trigger-specific interventions in the care plan. However, the resident’s care plan, developed for fluctuating mood symptoms related to anxiety and PTSD, did not include the preference to avoid male caregivers or any identified trauma triggers, despite a positive trauma screen and available psychiatric documentation.
The facility failed to complete a trauma-informed assessment and care plan for a resident following an alleged physical assault by another resident. A complaint indicated that a resident reported another resident entered the room, grabbed both hands, and punched the resident in the face multiple times. Record review showed no evidence that a trauma-informed assessment or trauma-focused care plan was completed after this incident. In an interview, the resident was tearful and reported ongoing fear, difficulty sleeping, and feeling scared when the alleged perpetrator entered the dining room. Facility leadership acknowledged that trauma-informed assessments were expected at admission and after a change in condition, but this was not done in this case.
A resident with documented PTSD and major depressive disorder, who reported a history of childhood sexual abuse, did not receive trauma-informed, culturally competent care as required by facility policy. The psychosocial evaluation incorrectly indicated the resident did not have PTSD, and the comprehensive care plan lacked any focus or interventions related to PTSD or trauma. No additional trauma screening or documentation of trauma-informed care was found in the clinical record, despite leadership stating that residents are expected to receive trauma-informed care.
A resident with PTSD, multiple sclerosis, and asthma, who was receiving Duloxetine and buspirone for PTSD and anxiety, reported that a male NA repeatedly entered her room in the early morning hours to check if she needed the restroom, which made her very uncomfortable due to a history of being raped at night during military service. Review of her trauma-informed care evaluation and care plan showed no identified PTSD triggers or related interventions. The social worker acknowledged that the facility did not provide trauma-informed care to eliminate or mitigate triggers that could cause re-traumatization.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
Surveyors identified that the facility failed to provide trauma-informed, person-centered care for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with PTSD, depression, polyneuropathy, and insomnia, and a Minimum Data Set assessment showed no cognitive impairment, a need for substantial assistance with activities of daily living, and a confirmed PTSD diagnosis. Despite this, the clinical record contained no documentation that the resident had been assessed for PTSD-related symptoms or triggers, and the resident’s care plan lacked any measures addressing the history of trauma, identifying triggers, or specifying interventions to minimize triggers or re-traumatization. In an interview, the Director of Nursing confirmed that the resident had not been assessed or care planned for PTSD, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Incorporate Known Trauma Trigger and Care Preference Into Care Plan
Penalty
Summary
The facility failed to provide trauma-informed, culturally competent care by not incorporating a known trauma trigger and related preference into a resident’s care plan. Facility policy on Trauma Informed Care and Culturally Competent Care required the center to identify triggers that may re-traumatize patients with a history of trauma and to add trigger-specific interventions to the care plan to decrease exposure and mitigate effects. The resident’s diagnoses included PTSD and major depressive disorder. Psychiatry notes from two visits documented that the resident had a trauma history of childhood abuse by stepfathers and a stated preference to not have male caregivers. Despite this information, review of the resident’s care plan, initiated for risk of distressed/fluctuating mood symptoms related to anxiety and PTSD, did not include any intervention reflecting the resident’s preference to avoid male caregivers or any identified trauma triggers. A trauma assessment completed later showed a positive trauma screen with a score of 4, but the care plan still lacked documentation of the trigger or related interventions. In an interview, the Nursing Home Administrator stated he would have expected the resident’s trigger of male caregivers to have been added to the care plan and in place, confirming that this had not occurred.
Failure to Complete Trauma-Informed Assessment After Alleged Resident-to-Resident Assault
Penalty
Summary
Surveyors found that the facility failed to provide trauma-informed care by not completing a trauma-informed assessment or care plan for a resident who experienced an alleged physical assault by another resident. A complaint reported that Resident #5 alleged another resident entered the room in the evening, grabbed both of the resident’s hands, and punched the resident in the face approximately five times. Record review showed that after this incident there was no documentation that a trauma-informed assessment had been conducted or that a trauma-informed care plan had been developed to address the resident’s trauma history or needs following the event. During an interview, Resident #5 was tearful and reported being in fear, afraid to go to sleep at night, and scared when the alleged perpetrator walked into the dining room. Interviews with facility leadership confirmed that trauma-informed assessments were expected to be completed at admission and after a change in condition, but this had not been done for Resident #5 following the reported assault.
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.
Failure to Provide Trauma-Informed Care for Resident With PTSD
Penalty
Summary
Surveyors found that the facility failed to provide trauma‑informed care to a resident with a diagnosis of PTSD. The resident, who also had multiple sclerosis and asthma and was receiving Duloxetine for PTSD and buspirone for anxiety, reported that a male NA repeatedly entered her room around 3:00 a.m. to ask if she needed to use the restroom. The resident stated this made her very uncomfortable and disclosed that she had been in the military and developed PTSD after being raped in the middle of the night. Review of her Trauma Informed Care Evaluation showed no identified triggers, and her care plan also contained no PTSD triggers or related interventions. During interview, the social worker confirmed that the facility failed to provide trauma‑informed care to eliminate or mitigate triggers that could cause re‑traumatization.
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