Failure to Assess and Document PTSD Triggers in Trauma-Informed Care
Penalty
Summary
The facility failed to adequately assess and document post-traumatic stress disorder (PTSD) symptoms and triggers for a resident with a significant trauma history. The resident had a documented history of physical abuse as a minor, including being tied up, gagged, and burned, and was diagnosed with PTSD, among other psychiatric and neurocognitive disorders. While the care plan acknowledged the trauma history and included a general intervention stating the resident was fine with both male and female caregivers, it did not specify PTSD symptoms or triggers, nor did it include interventions to address them. The electronic medical record lacked a PTSD-specific assessment, and other care plan sections related to behavior and mood did not reference PTSD triggers or symptoms. Interviews with facility staff revealed that knowledge of the resident's PTSD triggers, such as not closing doors or making the resident feel confined, was communicated verbally rather than documented in the care plan. Staff members were aware of the resident's trauma history and some specific triggers through word of mouth, but this information was not consistently or formally included in the care plan. The facility's policy required the development of a trauma-informed care plan when a history of trauma was identified, but this was not fully implemented for the resident in question.