Failure to Individualize Care Plans for Residents with Trauma and Mental Health Needs
Penalty
Summary
The facility failed to review and revise the care plans for two residents with trauma exposure and related mental health needs, as required by their own policies and federal regulations. Both residents had intact cognition and complex psychiatric histories, including diagnoses such as PTSD, depression, anxiety, and adjustment disorder. Despite these diagnoses and documented symptoms, their care plans lacked individualized interventions addressing their trauma triggers, coping mechanisms, and specific behavioral symptoms. For example, one resident reported not being offered any PTSD-related services and was unaware of any trauma-informed interventions in place, while the other resident had not discussed her past traumas with staff and did not recall being offered counseling services since admission. Care plan reviews revealed that interventions were generic and did not specify what would trigger the residents' PTSD, how staff should respond to trauma-related behaviors, or what specific actions should be taken during episodes of altered thought processes or hallucinations. The care plans also failed to address the residents' emotional and psychosocial needs in a person-centered manner, omitting details about their personal histories, trauma experiences, and preferred coping strategies. This lack of specificity meant that staff did not have clear guidance on how to support these residents in managing their mental health conditions. Interviews with staff, including CNAs, LPNs, and the DON, confirmed that care plans are relied upon to guide resident care, especially for unfamiliar residents. The DON acknowledged that trauma-informed care was not addressed in the care plans for these residents and that such information should be included to ensure appropriate care. The facility's policies require individualized, resident-centered care planning that incorporates personal history and trauma exposure, but these requirements were not met for the two residents in question.