Failure to Document Trauma-Related Triggers and Interventions in Care Plans
Penalty
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.