Failure to Identify and Care Plan Trauma Triggers for Resident with PTSD
Penalty
Summary
The facility failed to identify and document trauma triggers or develop an individualized trauma-informed care plan for a resident with a history of post-traumatic stress disorder (PTSD) and other mental health diagnoses. The resident, who was cognitively intact and independent in activities of daily living, reported having known triggers related to staff behavior, such as loud noises and being abruptly awakened. Despite the resident's willingness to discuss these triggers, no staff had engaged her in such conversations, and her care plan did not include any identified triggers or strategies to avoid re-traumatization. Review of the resident's assessments and care documentation revealed that trauma history was acknowledged, but specific triggers were either marked as "none" or left as "unknown," and there was no follow-up to clarify or update this information during subsequent assessments. Interviews with nursing staff and aides indicated a lack of awareness regarding the resident's PTSD diagnosis and potential triggers, and the care plan lacked individualized trauma-informed interventions. The facility's policy required assessment and documentation of triggers, but this was not reflected in the resident's records or care planning.