Failure to Assess and Care Plan for PTSD and Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that residents with a diagnosis of Post Traumatic Stress Disorder (PTSD) were appropriately assessed to identify the cause of their trauma and to minimize triggers or re-traumatization. For one resident with intact cognition and a history of childhood sexual abuse, there was no care plan in place addressing the cause of PTSD, potential triggers, or interventions to reduce the risk of re-traumatization. Trauma Informed Care Evaluations for this resident did not determine the cause of PTSD or identify potential triggers, and the resident reported that facility staff had not inquired about her trauma history. Similarly, another resident with severely impaired cognition and an active diagnosis of PTSD did not have a care plan addressing the cause of PTSD, triggers, or interventions to minimize re-traumatization. Trauma Informed Care Evaluations for this resident also failed to determine the cause of PTSD or identify potential triggers. Facility social services staff confirmed that the assessments did not capture the actual cause of trauma and that the care plans did not accurately reflect triggers for recurrence.