Failure to Develop and Implement Comprehensive Trauma-Informed Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed trauma-related triggers and individualized trauma-informed care approaches for two residents with a history of trauma. For one resident with diagnoses including anxiety, depression, bipolar disorder, and PTSD, assessments identified specific traumatic experiences, emotional responses, and potential triggers such as being touched, loud noises, lack of control, and certain anniversaries. The resident also identified activities that could help her cope. However, her care plan and Kardex did not document these triggers or resident-specific interventions to mitigate the risk of re-traumatization. Interviews with staff confirmed that trauma-related triggers were not included in her care plan, and staff were unable to identify or reference these triggers in her records. For another resident with severe cognitive impairment, Alzheimer's disease, aphasia, depression, PTSD, and a history of childhood sexual abuse, the trauma assessment indicated that his trauma could influence his resistance to bathing and other behaviors. While his care plan acknowledged his trauma history and included some general behavioral interventions, it did not specify his trauma-related triggers or preferences for male versus female caregivers, despite documentation in clinical notes that he responded better to male caregivers and benefited from paired care with female staff. The Kardex also lacked documentation of specific triggers and preferences, and staff interviews revealed inconsistent awareness of his trauma-related needs. Facility policy required individualized care plans to address past trauma and minimize exposure to triggers, but the care plans and Kardexes for both residents did not meet these requirements. Staff interviews confirmed that trauma-related triggers and interventions were not consistently documented or communicated, increasing the risk that staff would not be aware of or able to avoid re-traumatizing residents with PTSD. The deficiency was identified through interviews, document reviews, and direct observation of care planning practices.