Failure to Identify and Address PTSD Triggers in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) had identified triggers and interventions in place to eliminate or mitigate the risk of re-traumatization. Review of the resident's medical record showed an incomplete Social History and Trauma Assessment, which had been initiated but not completed. The resident's care plan did not address PTSD, nor did it include any identified triggers or interventions related to trauma. Interviews with facility staff, including a Licensed Nursing Assistant, an LPN, and the Social Worker, revealed that they were unaware of the resident's PTSD diagnosis and that the Social Worker had not completed the necessary assessment or interviewed the resident's guardian regarding trauma history and triggers. The Director of Nursing confirmed the absence of a care plan addressing PTSD triggers and interventions for this resident. Facility policy requires a multi-pronged approach to identifying trauma history, including direct inquiry about triggers and the development of individualized care plan interventions to minimize or eliminate re-traumatization. Despite these policy requirements, the facility did not complete the trauma assessment or incorporate trauma-informed care planning for the resident with PTSD. This resulted in a lack of staff awareness and absence of documented strategies to address the resident's trauma-related needs.