Failure to Document Trauma Trigger Assessments for Residents with Trauma Histories
Penalty
Summary
The facility failed to develop and document trauma trigger assessments for two residents with known histories of trauma. For one resident with a diagnosis of PTSD, the care plan identified a potential alteration in psychosocial well-being related to surviving a traumatic event and set a goal to minimize trauma triggers. However, staff were unable to locate a specific list of trauma triggers in the resident's records or in the care instructions provided to nursing assistants. Similarly, another resident with a history of trauma and diagnoses including depression and hallucinations had a care plan goal to minimize trauma triggers, but no specific triggers were documented in the resident's records. Interviews with facility staff, including the Resident Care Manager and the Director of Nursing Services, confirmed that trauma triggers for both residents were not identified or listed in the care plans or supporting documentation. This lack of documentation meant that staff did not have clear guidance on how to avoid or minimize trauma triggers for these residents, as required by the facility's policies and regulatory standards.