Failure to Assess and Care Plan Trauma-Informed Approaches for Resident with PTSD
Penalty
Summary
The facility failed to assess and care plan person-centered, trauma-informed approaches for a resident with a known history of trauma and a diagnosis of post-traumatic stress disorder (PTSD). The facility's policy requires a multi-pronged approach to identifying trauma history and triggers, including the use of assessment tools and direct inquiry with the resident. However, the resident's record did not contain any trauma-specific assessment, and the care plan lacked individualized interventions to prevent re-traumatization. The resident in question was admitted with multiple mental health diagnoses, including major depressive disorder, Alzheimer's disease, unspecified psychosis, panic disorder, and PTSD related to the death of her sister during childhood. Although the care plan acknowledged the PTSD diagnosis and referenced the traumatic event, it only included general interventions such as medication administration, encouragement to express feelings, and monitoring for symptoms of depression or anxiety. There were no documented efforts to identify specific trauma triggers or to develop targeted strategies to minimize re-traumatization, as required by facility policy. Interviews with staff revealed a lack of awareness regarding the resident's trauma history and the absence of trauma-informed care approaches. The Social Service Director confirmed that trauma-informed assessments were not being completed for residents with identified trauma, and direct care staff were unaware of the resident's PTSD diagnosis or any specific interventions related to her trauma. Staff noted the resident's sensitivity to environmental stimuli and recent distress related to news events, but had not been provided with guidance on how to address these issues in a trauma-informed manner.