Failure to Identify and Care Plan PTSD Triggers for Residents
Penalty
Summary
The facility failed to develop care plans that included identified triggers for residents diagnosed with Post-Traumatic Stress Disorder (PTSD), as required by their trauma-informed care policy. Specifically, three residents with PTSD did not have care plans that addressed their individual trauma triggers, which are necessary to prevent re-traumatization. For one resident, the care plan noted a history of traumatic events, including the loss of parents and sexual molestation, but did not identify or address specific triggers related to PTSD. Another resident's care plan referenced a traumatic, life-threatening illness but similarly lacked documentation of PTSD-related triggers. The third resident with a PTSD diagnosis also did not have a care plan that included a focus on or triggers related to PTSD. Staff interviews, including those with the Social Service employee and the Director of Nursing, confirmed that the care plans for these residents did not include the required identification of behavioral triggers associated with PTSD. The facility's policy indicated that all staff receive in-service training on trauma and trauma-informed care, emphasizing the importance of identifying and decreasing exposure to triggers. Despite this, the care plans reviewed did not meet these requirements for the sampled residents, as confirmed by staff during the survey.