Failure to Identify and Address Trauma-Based Triggers for Resident with PTSD
Penalty
Summary
The facility failed to identify and address trauma-based triggers for a resident diagnosed with posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). The resident's electronic medical record documented these diagnoses, and the care plan only addressed depression related to a stroke, with no mention of PTSD triggers or individualized interventions. Despite behavioral health notes indicating the resident experienced intrusive thoughts and flashbacks related to military service, as well as difficulty sleeping and anxiety, the care plan did not include strategies to prevent re-traumatization or address the resident's PTSD. Observations and interviews confirmed that the care plan lacked documentation of trauma-based triggers and individualized interventions for PTSD. The facility's policy required trauma-informed and culturally competent care, including universal screening for trauma exposure and individualized care planning in collaboration with residents and families. However, the care plan for this resident did not reflect these requirements, and staff acknowledged the omission after review. The deficiency was identified through observation, record review, and staff interviews.