Failure to Identify and Address Trauma Triggers in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma and PTSD had individualized interventions identified in their care plan to eliminate or mitigate triggers that could cause re-traumatization. The resident had documented psychiatric diagnoses of depression, anxiety, and PTSD, with ongoing symptoms including nightmares and flashbacks related to childhood sexual abuse. Despite this, the care plan only generally referenced a past experience of trauma without specifying any triggers or interventions to address the resident's needs. Interviews with multiple staff members, including the unit manager, LPN, and nursing assistant, revealed that they were unaware of the resident's trauma history or PTSD diagnosis. The social services assessments noted trauma history, but primarily referenced a car accident and the passing of the resident's husband, omitting the history of sexual abuse. The Director of Social Services confirmed knowledge of the resident's childhood sexual abuse and specific preferences, such as not liking to feel trapped, but acknowledged that these details were not addressed in the care plan.