Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive trauma-informed care plan for one resident with a documented history of trauma, specifically Post-Traumatic Stress Disorder (PTSD), vascular dementia, and anxiety. Despite the facility's policy requiring individualized care plans that identify and address trauma triggers, record review showed that the resident's medical record did not include a care plan for PTSD or any identified triggers. The most recent Minimum Data Set (MDS) assessment confirmed the resident had moderate cognitive impairment and an active diagnosis of PTSD, yet no trauma-specific interventions or trigger identification were documented in the care plan. Interviews with facility staff, including a nurse, unit manager, and the administrator, revealed an expectation that trauma assessments and care plans, including trigger identification, should be completed collaboratively by the care team, with the social worker initiating the process. However, the absence of a trauma-informed care plan for the resident indicated a breakdown in this process. The social worker responsible for these assessments was not available for interview, and no evidence was found in the record to show that the required trauma-informed interventions were developed or implemented.