Failure to Assess and Address Trauma History in Resident with PTSD
Penalty
Summary
The facility failed to assess and address the trauma history and related care needs for one resident diagnosed with PTSD, anxiety, major depression, and OCD. Despite the resident being cognitively intact and vocal about their traumatic experiences, including military incidents and domestic abuse, the facility did not conduct a comprehensive trauma assessment on admission or during quarterly reviews. The social service admission assessment did not identify any trauma history, and subsequent progress notes and care planning documents lacked documentation of trauma-related discussions or identification of triggers. Psychiatric evaluations documented the resident's history of trauma, including military service and the recent loss of a spouse, and recommended adjustments to medication. However, this information was not incorporated into the resident's care plan, and there was no evidence of follow-up or individualized interventions to address potential triggers or prevent re-traumatization. The care plan contained only general statements about monitoring for triggers and providing psychosocial support, without specific strategies tailored to the resident's known trauma history. Interviews with facility staff revealed a lack of clarity regarding responsibility for trauma assessments and care planning. Social workers acknowledged that trauma assessments should be completed on admission and quarterly, and that care plans should include identified triggers, but were unable to explain why this was not done for the resident. The Director of Nursing confirmed that social services are responsible for trauma assessments and care plan updates, but also noted the absence of documentation related to the resident's trauma and triggers since admission.