Failure to Assess and Address Trauma Triggers and Mental Health Needs
Penalty
Summary
The facility failed to acknowledge and assess the underlying causes of a resident's expression of distress and did not develop or implement a care plan that addressed this distress, resulting in deterioration of the resident's mental and psychosocial well-being and self-harm. The resident had a documented history of adjustment disorder, borderline personality disorder, anxiety, major depressive disorder, and PTSD, with multiple incidents of self-harm and suicidal ideation following a recent change in living situation and increased dependence on staff for activities of daily living. Despite repeated behavioral incidents and clear documentation of trauma history and triggers, the facility did not adequately identify or mitigate these triggers, nor did it ensure consistent access to mental health services, as evidenced by a lapse in behavioral health follow-up and lack of trauma-informed interventions in the care plan. The medical record contained multiple entries describing self-harming behaviors attributed to psychosocial adjustment difficulties, including hitting, slapping, and cutting oneself, as well as threats of self-harm. These behaviors were often linked to specific triggers, such as feeling helpless, not being listened to, or unmet needs, particularly during episodes of incontinence or negative staff interactions. The facility's own trauma-informed care policy required identification and mitigation of trauma triggers, but interviews with staff confirmed that the resident was not asked about trauma or triggers, and information provided by case workers regarding triggers was not incorporated into the care plan. Additionally, the facility failed to update care plans for seven other residents with diagnoses of trauma and/or PTSD to include triggers associated with their trauma. Staff interviews confirmed that these care plans did not have identified triggers until after the survey. This deficiency was a repeat occurrence, having been cited during the previous recertification survey, and reflects a pattern of not following internal policies regarding trauma-informed care and person-centered care planning for residents with mental health and trauma histories.