Failure to Identify and Document Trauma Triggers in Care Plan
Penalty
Summary
The facility failed to ensure that trauma triggers were properly identified and documented for a resident with a known history of trauma and PTSD. Interviews and record reviews revealed that the resident experienced distress after witnessing an altercation between other residents, specifically being upset by hearing threatening language. The resident's social history and social services assessments both indicated a history of trauma and the presence of trauma triggers, but did not specify what those triggers were, despite the resident exhibiting symptoms such as anxiety, fear, irritability, mood changes, and sleep disturbances. Further investigation showed that staff were aware of the resident's trauma triggers, including loud noises and confrontation, but these were not included in the resident's care plan. The care plan referenced the resident's history of trauma and noted an incident where PTSD was triggered by a verbal argument, but failed to identify loud noises as a specific trigger. The facility's own policy requires that trauma triggers be identified and included in care plans to prevent re-traumatization, but this was not followed in this case.