Failure to Assess and Care Plan for PTSD Triggers in Resident
Penalty
Summary
The facility failed to adequately assess and provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). Despite the facility's policy requiring staff to provide trauma-informed and culturally competent care, including working with residents and families to identify strengths and minimize triggers, the resident's comprehensive care plan did not document their history of trauma or identify specific triggers. The resident, who had experienced two separate traumatic events, reported discomfort with certain situations, but this information was not reflected in their care plan. Interviews with facility staff revealed that there was no specific assessment process in place to identify PTSD triggers for residents. The social worker confirmed that the initial social services assessment did not include discussions about triggers or PTSD-related concerns, and the care plan lacked any reference to PTSD or associated interventions. The Director of Nursing stated that residents with PTSD should receive trauma-informed care and have their triggers identified and included in their care plans, but this was not done for the resident in question.