Failure to Assess and Document PTSD Triggers for Resident
Penalty
Summary
The facility failed to adequately assess and document the trauma history and potential triggers for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident's quarterly Minimum Data Set indicated diagnoses of anxiety, depression, and PTSD, and a trauma screening assessment noted a traumatic event and a referral for counseling. However, the assessment did not include details about the traumatic event or identify any specific triggers. The resident's care plan referenced PTSD and included general interventions such as therapy referral, chaplain visits, and consistent staffing, but did not specify any triggers or trigger-specific interventions. Progress notes from an outside provider confirmed ongoing treatment for PTSD and depression. Interviews with the resident revealed that staff often entered the room without knocking, including when the resident was undressed, and that the resident disliked being surprised or approached from behind due to PTSD. The resident was unsure if staff were aware of her PTSD or had discussed it with her. Nursing staff and nursing assistants were not aware of the resident's PTSD diagnosis or any associated triggers, and this information was not present in their task sheets. The Director of Social Services confirmed that trauma assessments should identify triggers and that this information should be included in the care plan, but was unaware of any triggers for this resident. Facility policy required identification of trauma history and triggers, with trigger-specific interventions documented in the care plan, but this was not done for the resident in question.