Failure to Assess and Address PTSD Symptoms in Veteran Resident
Penalty
Summary
The facility failed to identify, assess, and address potential signs and/or symptoms of Post Traumatic Stress Disorder (PTSD) for one resident who was reviewed for mood and behavior. The resident, a Navy veteran with diagnoses including dementia, depression, and violent behavior, exhibited severe cognitive impairment and worsening verbal and physical behaviors that interfered with care and the living environment. Despite frequent episodes of yelling, screaming, and distress—often occurring at night and sometimes while the resident was asleep—there was no documented assessment or intervention specifically targeting possible PTSD or trauma-related symptoms. Facility policy required monitoring and assessment for signs of trauma and PTSD, as well as staff training in trauma-informed care. However, the resident's behavioral care plan only addressed general behavioral symptoms related to dementia and poor impulse control, without considering trauma or PTSD as a potential underlying cause. The psychosocial evaluation noted the resident was a veteran and had no family support, but did not identify any significant traumatic events, and the resident was described as unwilling to discuss trauma. Nursing progress notes documented ongoing episodes of yelling, screaming, and distressing outbursts, particularly at night, with some entries noting the resident was unaware of their own behavior or reported having bad dreams. Interviews with staff revealed a lack of trauma-informed care training and an absence of specific assessment or interventions for PTSD, despite staff awareness that the resident was a veteran and exhibited behaviors consistent with trauma-related symptoms. The Social Services Coordinator and DON both acknowledged that the resident had not been assessed for PTSD, and no interventions had been implemented to address the recurrent nightmares or night terrors. The facility's failure to follow its own policy and to provide trauma-informed care resulted in unmet behavioral health needs for the resident.