Failure to Document Trauma-Related Triggers and Interventions in Care Plans
Summary
The facility failed to ensure that trauma-related triggers and individualized trauma-informed interventions were documented in the comprehensive care plans for two residents with a history of trauma. One resident, who had diagnoses including PTSD, anxiety, depression, and bipolar disorder, had completed a trauma assessment identifying specific traumatic experiences, emotional responses, and potential triggers such as being touched, loud noises, lack of control, and certain anniversaries. The assessment also listed activities that could help her cope. However, her care plan and Kardex did not include these identified triggers or resident-specific interventions to mitigate the risk of re-traumatization. Staff interviewed were unable to identify her trauma-related triggers and confirmed that such information was not present in the care documentation they used. Another resident, who had severe cognitive impairment, aphasia, and a history of childhood sexual abuse, was also missing documentation of trauma-related triggers in his care plan and Kardex. Although his care plan acknowledged his trauma history and included some general behavioral interventions, it did not specify his preference for male versus female caregivers, despite clinical notes indicating he responded better to male caregivers and benefited from paired care with female caregivers. Staff interviews revealed a lack of awareness of his trauma-related triggers and preferences, and the recommended interventions from clinical notes were not consistently transcribed into the care plan or Kardex. Staff relied on word of mouth and daily huddles for information, but key details were not formally documented. Facility policy required individualized care plans to address past trauma and identify and decrease exposure to triggers that may re-traumatize residents. Despite this, the care plans and Kardexes for both residents lacked the necessary documentation of triggers and specific interventions. Multiple staff members, including nursing assistants, nurses, and social services, confirmed that trauma-related triggers and recommended interventions were not present in the care documentation, which could have impacted the care provided to these residents.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with PTSD, anxiety, and depression did not have a trauma-informed assessment completed on admission, and the care plan did not include trauma-related triggers, interventions, or strategies to promote emotional safety. The resident stated staff did not ask about past trauma or triggers, and an NA was unaware of any PTSD-related interventions. The DON, SSD, and administrator stated the TIC assessment was missed when the resident was admitted.
A resident with depression, anxiety, and skin-picking disorder disclosed a past sexual assault, but the trauma assessment was incomplete and the care plan lacked trauma-specific focus, goals, or interventions. The SW acknowledged the resident’s trauma history and stated a new assessment and care plan update should have been completed but were not.
Failure to complete trauma-informed care assessments for two residents with PTSD. One resident had PTSD, MDD, and anxiety with severely impaired cognition, and the other had PTSD with intact cognition and reported combat-related PTSD. Neither EMR documented a trauma-informed assessment or an offer of behavioral health counseling, and the DON acknowledged both residents were not offered counseling services.
Failure to address PTSD and trauma triggers: A cognitively intact resident with PTSD, anxiety, ADHD, autistic disorder, and a history of childhood sexual abuse reported that a CNA washed his genitals and continued care after he asked her to stop, which triggered him. He also reported a separate incident where an RN gave meds without turning on the light or explaining what she was doing, leading to an escalation that included throwing water pitchers and law enforcement being called. The record lacked documentation of his PTSD/trauma triggers and of ways to ensure an emotionally and physically safe environment.
A resident with schizophrenia and moderate cognitive impairment had documented childhood physical abuse and a positive trauma-informed care assessment, but no trauma-informed care plan was included in the care plan. The facility policy called for individualized interventions to identify triggers and reduce re-traumatization, and both the SW and NHA confirmed a trauma care plan should have been in place.
Failure to Identify PTSD Triggers and Provide Trauma-Informed Care: A resident with PTSD, depression, insomnia, and a history of war trauma was observed in a dark room with the door closed because bright lights and loud noises triggered nightmares. Staff stated they were unaware of his specific triggers, and the care plan contained only generic PTSD interventions rather than resident-specific approaches. The SSD was not aware of the triggers, and the DSD could not provide evidence of trauma-informed care in-service training.
Missing Trauma-Informed Assessment and Care Planning
Penalty
Summary
The facility failed to implement a trauma-informed approach for one resident with a history of PTSD, anxiety, and depression. The resident’s admission MDS identified moderate cognition and a need for assistance with ADLs, but the care plan dated 6/4/26 did not include trauma-informed interventions, approaches to minimize triggers, or strategies to promote emotional safety. The resident stated that past trauma caused bad dreams and affected the ability to fall asleep, and also stated that staff had not asked about past trauma or potential triggers upon admission. The resident’s medical record lacked evidence that a trauma assessment was completed on admission to identify past trauma, triggers, or individualized trauma-related care needs. A nursing assistant stated she was not aware of any PTSD-related interventions for the resident, although staff were expected to review care plans for PTSD triggers and interventions. The DON, SSD, and administrator stated trauma-informed care assessments were supposed to be completed for new admissions, but the SSD was unaware the assessment had been missed when the resident was admitted and the administrator stated the resident’s TIC assessment was not completed upon admission.
Incomplete trauma assessment and care plan for resident with disclosed sexual assault history
Penalty
Summary
The facility did not ensure trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and the resident’s experiences and preferences. For 1 of 3 residents reviewed for trauma-informed care, R102 disclosed a history of sexual assault, but the resident did not have a complete trauma assessment or a care plan addressing triggers, resident-specific approaches, or interventions. R102 was admitted with diagnoses including depression, anxiety, and skin-picking disorder, and had a BIMS score of 14, indicating cognitive intactness. R102’s Trauma Informed Care Assessment dated 6/8/26 contained multiple blank responses, including items related to physical assault, life-threatening illness or injury, severe human suffering, and other stressful events, and the PC-PTSD-5 screening questions were also left blank. On 6/30/26, R102 told the surveyor about a past sexual assault. The comprehensive care plan printed 7/1/26 did not include any trauma-specific focus, goals, or interventions. The Social Worker stated she had been told on 6/25/26 or 6/26/26 about the traumatic sexual incident from when R102 was a teenager, and acknowledged that a new trauma assessment and care plan update should have been completed but were not.
Failure to Complete Trauma-Informed Care Assessments for Residents with PTSD
Penalty
Summary
The provider failed to complete trauma informed care assessments for two residents with PTSD diagnoses and did not document that behavioral health counseling was offered. One resident admitted with PTSD, major depressive disorder, and anxiety disorder had a BIMS score of 5, indicating severely impaired cognition, and her revised care plan did not include goals or interventions related to PTSD. Her EMR contained no documentation of a trauma informed care assessment to identify related needs or any offer of counseling. She was observed in bed with the television on and was nonverbal when questioned, and her emergency contact reported that staff kept him updated, he attended care meetings, and he had no concerns about her care. The second resident admitted with PTSD had a BIMS score of 15, indicating intact cognition, and his care plan identified altered mood and behaviors related to PTSD with interventions such as allowing him to choose activities, stopping to talk to him, and allowing positive interactions. His EMR also contained no documentation of a trauma informed care assessment or an offer of behavioral health counseling. He stated that he had PTSD from combat, that the facility did not offer much support for it, that he was not offered counseling services, and that he would like a referral for counseling. The SSD stated she had been unaware she was responsible for completing trauma informed care assessments until approximately three months earlier, and the DON acknowledged that both residents lacked the required assessments and were not offered counseling services.
Failure to Address PTSD and Trauma Triggers
Penalty
Summary
The facility failed to protect a resident’s psycho-social well-being by not addressing trauma-related triggers for a resident with PTSD. Resident B stated he was sexually touched inappropriately as a child and did not want anyone to touch his genitalia. He reported that after being told he could shower independently when admitted, a CNA came to assist with a shower, insisted on washing him after he said not to touch him, and used washcloths to wash his legs, feet, genitals, head, and face while he repeatedly asked her to stop. He stated that washing his genitals triggered him. He also identified fire alarms, smoke, verbal and physical violence as PTSD triggers. Resident B’s record showed diagnoses including cerebral palsy, PTSD, ADHD, anxiety, and autistic disorder, and a BIMS score of 15 out of 15 indicating he was cognitively intact. His care plan noted a history of trauma related to sexual abuse and included a goal to create an emotionally and physically safe environment, with approaches such as providing Play-Doh or another preferred activity when he expressed anxiety or agitation. Trauma-informed assessments completed in February and May indicated abuse, violence, or sexual assault had been events in his life that caused problems for him, and that he had been abused as a child but did not want to discuss details. However, the record lacked documentation of his PTSD and trauma triggers and lacked documentation of ways to ensure his environment was emotionally or physically safe for him related to his PTSD and trauma. He also reported another incident in which a nurse entered his room early in the morning and shoved medication in his mouth without turning on the light or telling him what she was doing, which led to a response that included throwing water pitchers and law enforcement being called.
Missing Trauma-Informed Care Plan
Penalty
Summary
The facility did not ensure that a resident with a history of trauma received culturally competent, trauma-informed care in accordance with professional standards of practice. The resident had diagnoses including schizophrenia and a Quarterly MDS assessment showing a BIMS score of 12, indicating moderate cognitive impairment. The resident’s Psychosocial Assessment documented a history of childhood physical abuse by the father, and the Trauma Informed Care Assessment indicated the resident had experienced a traumatic event. Despite this information, the resident’s care plan did not include a trauma informed care plan. The facility policy stated that residents who are trauma survivors should have individualized care plan interventions that identify triggers and reduce exposure to re-traumatization. During interview, the Social Worker stated that if the Trauma Informed Care Assessment was positive, a trauma informed care plan would be implemented, and after reviewing the resident’s records, acknowledged that no such care plan was in place. The Nursing Home Administrator also stated that a trauma informed care plan would be expected for a resident with a childhood history of physical abuse and confirmed that the resident was not care planned for trauma.
Failure to Identify PTSD Triggers and Provide Trauma-Informed Care
Penalty
Summary
The facility failed to identify and intervene on events related to one resident’s history of trauma and triggers that could cause re-traumatization. The resident was admitted with diagnoses including PTSD, depression, insomnia, and left eye blindness, and the H&P documented that he had the capacity to understand and make decisions. The MDS showed he required assistance with several activities of daily living, including oral hygiene, showering, dressing, toileting hygiene, bed mobility, transfers, and eating. During observation and interview, the resident was found in a dark room with the door closed and curtains drawn. He stated he wanted the room dark and the door closed because he was sensitive to bright lights and loud noises, and that exposure to those stimuli caused nightmares about the war. He also stated he was a veteran and suffered from traumatic war experiences, and that he took a sleeping pill due to insomnia. A restorative nursing assistant stated the resident preferred his room to remain dark and the door closed most of the time, but she did not know about his PTSD triggers. Record review showed the care plan for ineffective coping due to PTSD included a goal for the resident to remain free of PTSD symptoms and general approaches to monitor for early signs of PTSD symptoms and encourage him to identify and avoid known triggers, but the RN supervisor stated the plan did not identify the resident’s specific triggers and was generic rather than resident-specific. The social service director stated she was not aware of the resident’s PTSD triggers such as bright lights and loud noises because he did not mention them, and the director of staff development could not provide evidence that trauma-informed care in-service training had been completed. The DON stated that when a resident with PTSD is admitted, the SSD should assess the resident for triggers and past history to prevent re-traumatization, and stated that re-traumatization would harm the resident’s psychosocial well-being.
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