Failure to Complete Accurate Trauma-Informed Assessment for Resident with PTSD
Penalty
Summary
The facility failed to ensure an accurate trauma-informed care assessment was completed for a resident with a known history of Post-Traumatic Stress Disorder (PTSD). The resident, who served as a sniper in the military during wartime and had been run over by an automobile prior to admission, reported experiencing PTSD symptoms such as nightmares and identified specific triggers, including the sound of helicopters. Despite these disclosures, the trauma-informed care assessment documented that the resident had not experienced traumatic events, and his PTSD symptoms and triggers were not identified in his records. Interviews with facility staff revealed that the social services staff relied solely on information from a family member and was unaware of the resident's military background and war experience. The LPN assigned to the resident was also unaware of his PTSD diagnosis or triggers. The Director of Nursing confirmed that the expectation was for an accurate trauma-informed assessment to be completed to identify triggers and prevent re-traumatization. The resident's admission record and MDS confirmed a diagnosis of PTSD and cognitive intactness, yet the assessment failed to reflect his trauma history and symptoms.