Failure to Identify Triggers and Implement Trauma-Informed Care for Resident with History of Abuse
Penalty
Summary
The facility failed to identify triggers, develop a care plan, and implement appropriate interventions and services for a resident with a past history of abuse, affecting three residents reviewed for abuse. One resident, who is cognitively intact but has multiple diagnoses including paraplegia, anxiety disorder, cerebral palsy, intellectual disability, and major depressive disorder, reported being physically struck by another resident. This incident triggered memories of past abuse by the resident's mother, leading to increased anxiety, fear, and emotional distress. The resident expressed fear and nervousness whenever encountering the other resident involved in the altercation, and staff confirmed the resident's emotional reactions and avoidance behaviors. Despite the facility's policy on trauma-informed care, which requires screening for trauma, identification of triggers, and individualized care planning, the resident's care plan did not include specific details about the history of abuse, associated triggers, or tailored interventions. The care plan only included a general intervention to keep the resident away from others who might trigger behaviors, without addressing the underlying trauma or providing detailed strategies to mitigate re-traumatization. The social service assessment acknowledged a history of abuse and trauma but lacked further detail, and the psychiatric provider was unaware of the resident's abuse history due to lack of documentation and communication from staff. Interviews with staff and family revealed that the resident's history of abuse and specific triggers were known to some staff and family members but were not consistently documented or communicated among the care team. The psychiatric provider stated that if made aware of the abuse history, additional interventions such as psychotherapy and medication adjustments could have been considered. The resident had not received psychotherapy services in the past six months, and the new LCSW had not yet seen the resident. The lack of comprehensive assessment, care planning, and implementation of trauma-informed interventions resulted in the resident experiencing ongoing distress and inadequate psychosocial support.