Failure to Identify Trauma Triggers for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of post-traumatic stress disorder (PTSD) received trauma-informed, culturally competent care in accordance with professional standards. Record review showed that the resident's care plan acknowledged a history of trauma and included general interventions such as approaching the resident calmly and avoiding startling her. However, the care plan did not identify any specific triggers related to the resident's trauma, despite her documented PTSD diagnosis. The resident's social history and psychiatric assessments also lacked documentation of trauma triggers, and there was no evidence of a trauma assessment being completed after regulatory changes. Interviews with facility staff, including the Social Worker, DON, and Assistant Administrator, revealed that staff were aware of the importance of identifying trauma triggers but could not confirm that this had been done for the resident in question. The Social Worker stated she did not recall assessing the resident for trauma or identifying triggers, and the DON and Assistant Administrator both indicated that care plans should include specific triggers to prevent re-traumatization. A policy for trauma-informed care was requested by surveyors but was not provided before the survey exit.