Failure to Identify PTSD Triggers and Implement Trauma-Informed Interventions
Penalty
Summary
The facility failed to provide trauma-informed care for two residents diagnosed with post-traumatic stress disorder (PTSD). For one resident, the care plan documented diagnoses including hypertension, anxiety, nicotine dependence, PTSD, schizoaffective disorder, bipolar disorder, and insomnia. Although the care plan addressed general symptoms of anxiety and included some interventions such as maintaining routines and monitoring medication, it did not identify the specific trauma that caused the PTSD or any individualized triggers that could lead to re-traumatization. The care plan also lacked personalized interventions to assist the resident in coping with PTSD, and the assessment documented no PTSD issues reported, despite the diagnosis being present in the medical record. For the second resident, the care plan acknowledged a history of PTSD and noted that the resident could be easily startled or feel detached from others. However, the care plan did not provide staff with specific information about the trauma, potential triggers, or interventions to prevent re-traumatization. The resident's assessments included regular PTSD screenings, but these did not document the specific trauma or possible triggers. Staff interviews revealed an expectation that care plans should include this information, but it was not present in the documentation reviewed. The facility's policy on trauma-informed care required that residents who are trauma survivors receive care that accounts for their experiences and preferences, including the identification of trauma and potential triggers. Despite this policy, the care plans and assessments for both residents did not meet these requirements, as they failed to identify trauma-based triggers or implement individualized interventions to prevent re-traumatization.