Failure to Assess and Care Plan for Trauma and PTSD in Residents
Penalty
Summary
The facility failed to ensure that residents with Post Traumatic Stress Disorder (PTSD) or a history of trauma were appropriately assessed to identify the causes of their trauma, potential triggers, and to implement care plans aimed at minimizing re-traumatization. Record reviews and interviews revealed that for five residents with PTSD or trauma histories, there were no comprehensive assessments conducted to determine the specific causes of their trauma or to identify triggers that could lead to re-traumatization. In several cases, care plans either did not exist or lacked interventions tailored to the residents' trauma-related needs. For example, one resident with multiple diagnoses including PTSD and severely impaired cognition had no care plan addressing the cause of PTSD, potential triggers, or interventions to reduce re-traumatization. Another resident, cognitively intact and reporting symptoms consistent with trauma, was not provided with a care plan that addressed her trauma or included interventions for staff to use in case of adverse reactions. Similarly, a resident who experienced a traumatic motor vehicle accident and exhibited emotional distress had no further assessment or care plan related to trauma triggers or symptoms. Additional residents with trauma histories, including one with PTSD and another with acute pain due to trauma and anxiety disorder, were not adequately assessed for causes or triggers of their trauma. Their care plans either lacked trauma-specific interventions or were entirely absent. Interviews with the DON confirmed that these assessments and care plans had not been completed, and that the facility had not taken steps to minimize the risk of re-traumatization for these residents.