Failure to Identify and Address Trauma Triggers for Resident with PTSD
Penalty
Summary
The facility failed to identify and address trauma triggers for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD). Upon admission, the resident's initial trauma screening confirmed a history of trauma and ongoing symptoms, but did not document specific trauma triggers. The psychiatric follow-up report referenced a significant history of psychiatric trauma from an abusive relationship but did not include details about potential triggers. Additionally, when the resident was re-admitted after a hospitalization, the trauma screening section of the nursing assessment was left blank, and no further assessment for trauma triggers was completed. The care plan for the resident did not include any interventions or instructions related to trauma-informed care or PTSD, leaving staff without guidance on how to identify or mitigate trauma triggers. Interviews with the nurse manager and social worker revealed that neither was aware of the resident's specific trauma triggers, and both acknowledged that an assessment and care plan should have been completed. The facility's policy requires screening for trauma history and the development of a care plan to address potential triggers, but this was not followed in the resident's case.