Failure to Assess and Identify PTSD Triggers for Resident
Penalty
Summary
The facility failed to assess and identify trauma triggers for a resident diagnosed with PTSD, as required for trauma-informed care. The resident's electronic medical record documented a history of PTSD, dementia with psychotic disturbances, anxiety, and depression. However, quarterly social service assessments did not mention PTSD, and there were no physician orders to monitor for PTSD-related triggers or behaviors. Interviews revealed that the resident had experienced significant trauma, including childhood abuse, sexual assault, and domestic abuse, and continued to experience symptoms such as nightmares and anger issues. Despite this, staff were either unaware of the resident's trauma history or did not recognize or document her triggers. The facility's policy required identification of trauma survivors and assessment of trauma and triggers during admission and at least annually, but this was not followed for the resident in question. The social worker acknowledged the resident's PTSD diagnosis and history of trauma but stated she was unaware of any triggers, despite evidence of ongoing symptoms. The MDS nurse also confirmed the PTSD diagnosis from hospital records but did not know the specifics of the trauma or triggers. This lack of assessment and documentation resulted in a failure to provide trauma-informed care as outlined in the facility's policy.