Failure to Update Care Plan and Document Trauma-Informed Interventions After Adverse Event
Penalty
Summary
A resident with a history of significant trauma, including kidnapping, sexual assault, and multiple family suicides, was admitted to the facility with diagnoses such as PTSD, bipolar disorder, and anxiety. The resident was cognitively intact and had documented triggers, including loud noises and a need for control and choices in her care. Despite these documented needs, the care plan did not include the resident's preference for female caregivers only, even though this preference was relevant to her trauma history. On a specific date, the resident experienced an adverse event when she required assistance with personal care and requested a female staff member. She was informed by a male CNA that a female staff member was unavailable and would not be able to assist her for several hours. The resident, uncomfortable with a male caregiver, ultimately received care from the male CNA, during which she reported feeling re-traumatized due to the manner in which care was provided. She later disclosed the incident to a nurse, who reported it according to facility policy. Subsequent review of the resident's care plan, electronic medical record, and nurse aide Kardex revealed no documentation of her preference for female caregivers or avoidance of male caregivers, despite her trauma history and the recent incident. Interviews with staff indicated a lack of awareness regarding the resident's PTSD triggers and care preferences, particularly among float staff who were not regularly assigned to her care. The facility's trauma-informed care policy required identification of trauma history and triggers, as well as the development of individualized care plans and interventions, but these were not fully implemented for this resident.