Failure to Identify and Address PTSD Triggers in Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care to a resident with a diagnosis of post-traumatic stress disorder (PTSD). The facility's policy on trauma-informed and culturally competent care requires staff to develop individualized care plans that address past trauma, identify triggers, and minimize exposure to those triggers in collaboration with the resident and family. However, review of the resident's care plan showed that while it acknowledged the risk for decreased psychosocial well-being and adjustment issues related to a history of assault with a weapon, it did not identify specific PTSD triggers or outline strategies to avoid them. Further review of the resident's clinical record confirmed the diagnosis of PTSD, along with anemia and a hip fracture. During an interview, the Social Services Director acknowledged that the facility did not identify or address the resident's PTSD triggers, which is necessary to eliminate or mitigate potential re-traumatization. This deficiency was cited under the relevant state codes for responsibility of the licensee and management.