Failure to Assess Trauma History and Provide Trauma-Informed Care Planning
Summary
The facility failed to appropriately assess a resident with a history of past traumatic experiences and failed to implement person-centered, trauma-informed care plan interventions for one resident with an active diagnosis of PTSD, major depressive disorder, anxiety disorder, bipolar disorder, and mild cognitive impairment. The resident’s quarterly MDS dated 7/8/25 indicated mild cognitive impairment, wheelchair use for mobility, and dependence on staff for hygiene, bathing, dressing, and positioning. The resident’s care plan lacked individualized trauma-informed approaches and did not identify triggers to avoid potential re-traumatization, and the EHR lacked evidence that the facility assessed the resident for trauma. During observations, the resident was repeatedly calling out for staff assistance and asking staff to sit with him; staff sat with him briefly and then left the room. The resident later yelled for help and stated he wanted staff to sit with him again to assist him with eating breakfast, after which he resumed eating without assistance. During interviews, a NA and RN stated they did not know the resident’s trauma history or triggers and confirmed the care plan did not address PTSD. The DON and administrator confirmed the resident had an active PTSD diagnosis, lacked an individualized trauma-informed care plan, and that the trauma assessment was not completed until 12/4/25 and was not followed up. The administrator stated the resident’s PTSD was related to the unexpected suicide death of his brother and that the resident became sad and upset when his family had not visited recently.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Provide Trauma-Informed Care for Residents with PTSD: The facility did not ensure staff knew which residents had PTSD or what their triggers were, and it did not document resident-specific PTSD approaches, measurable goals, or behavior monitoring for two residents with significant mental health histories. One resident reported anxiety when leaving the facility and said staff had never discussed her PTSD, while another resident had a trauma history with current depressed and anxious symptoms, but the care plan and TAR lacked documented interventions and staff were unaware of her triggers.
Failure to Address PTSD Triggers and Supportive Interventions: The facility did not identify, assess, or include trauma history, triggers, or non-pharmacological interventions in the care plans for three residents with PTSD. One resident had documented trauma, abuse history, nightmares, irritability, and anxiety; another reported recurring bad dreams and triggering resident behaviors; and a third had PTSD with psychotropic medications and observed mood changes and distractibility. Staff interviews confirmed PTSD care plans should include triggers and interventions, but the plans did not reflect those needs.
Failure to identify PTSD triggers in care plans. Surveyors found that two residents with PTSD had care plans with general psych and psychosocial interventions, but no documented trauma-informed assessment or specific triggers. Staff, including the DSS, LPN, CNA, and CPA, confirmed they did not know the residents’ triggers or trauma history, and one resident had behaviors such as crying frequently, picking at a colostomy bag, and eating scabs that were not fully documented.
A resident with PTSD related to military service was not timely reassessed for trauma-informed needs after readmission, and the social services assessment did not address PTSD, triggers, or coping mechanisms. The care plan later noted depressed mood and flashbacks but missed loud noises as a trigger, even though the resident became agitated when discussing trauma and reported that noise from neighboring rooms was bothersome. Staff knew about the resident’s noise-related anxiety and complaints, but the concerns were not fully documented or incorporated into the care plan.
Missing Trauma Assessments and Trauma-Informed Care Planning The facility failed to ensure trauma-informed care for two residents. One resident with severe cognitive impairment had known trauma and triggers related to men and confinement, but her trauma assessment, social history, and baseline care plan did not include that information. Another resident with PTSD and anxiety had no trauma assessment or trauma screen in the record, despite staff awareness of reported prior sexual trauma. The DON, SW, and other staff acknowledged the missing or incomplete documentation.
The facility failed to provide trauma-informed care for two residents with PTSD by not identifying specific triggers in their care plans. One resident had PTSD related to sexual abuse, depression, and dysphagia, and the care plan did not identify triggers even though a psychiatry note referenced a trigger involving a resident who looked like the assailant. Another resident had PTSD related to past trauma, anxiety, COPD, alcohol use, and HTN, but his care plan also lacked specific PTSD triggers; staff interviews showed limited knowledge of the residents’ triggers.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to ensure residents with PTSD received trauma-informed and culturally competent care in accordance with professional standards of practice, including accounting for residents’ experiences and preferences to eliminate or mitigate triggers that could cause re-traumatization. The deficiency involved 2 of 13 residents reviewed for quality of care, Residents #8 and #44. Survey findings showed the facility did not ensure nursing staff were aware of residents diagnosed with PTSD or their triggers, did not develop and ensure staff were educated in PTSD triggers and interventions for these residents, and did not monitor Resident #44 for signs and symptoms of anxiety, depression, and suicidal thoughts. Resident #8 was a female admitted with diagnoses including major depressive disorder, schizophrenia, PTSD, and alcohol dependence. Her quarterly MDS documented a BIMS score of 6 out of 15, indicating severely impaired cognition, and her active diagnoses included PTSD. Her care plan documented incontinence, fall risk, antidepressant use, and impaired visual function, but the Treatment Administration Record contained no documentation of behavior monitoring approaches, measurable objectives, or resident goals related to PTSD. During interview, Resident #8 stated her main trigger was leaving the facility, that she became anxious when she had to go out, and that staff had never spoken with her about her PTSD or anxiety. Resident #44 was a female admitted with diagnoses including diabetes, PTSD, chronic pain, generalized anxiety disorder, obesity, and major depressive disorder. Her MDS documented a BIMS score of 5 out of 15, indicating severely impaired cognition, and her active diagnoses included PTSD. Her care plan identified a history of trauma/PTSD related to past sexual and physical abuse from loved ones and included a goal for staff to assist in avoiding triggers, with interventions to arrange a licensed mental health provider, consult with family, and monitor for escalating anxiety, depression, or suicidal thought. However, the comprehensive care plan and Treatment Administration Record did not contain documentation of behavior monitoring specific approaches, measurable objectives, or resident goals related to PTSD. A psychological services note documented that the resident screened positive for trauma with current symptoms and was depressed, anxious, and felt worthless, but no interventions were listed. Staff interviews showed multiple staff members were unaware that Residents #8 and #44 had PTSD or what their triggers were, and one RN stated she had not been trained on trauma-informed care or PTSD. The DON stated staff were trained to pay attention to behaviors and that knowledge about trauma would come from the SW and care plan, but she was not aware of the residents’ trauma histories or triggers. The facility policy stated residents who are trauma survivors must receive culturally competent, trauma-informed care, triggers must be identified, and resident-specific approaches must be developed and included in the care plan.
Failure to Address PTSD Triggers and Supportive Interventions
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for three residents with PTSD. The facility policy titled, Policy and Procedure PTSD, required identification, assessment, care planning, service delivery, documentation, and follow-up for residents with a history of trauma and/or PTSD to promote safety, dignity, psychosocial well-being, and quality of life. However, the care plans for the three sampled residents did not include trauma history, triggers, or non-pharmacological interventions related to PTSD or related behaviors. One resident had diagnoses including PTSD, major depressive disorder, schizoaffective disorder depressive type, and suicidal ideations. The resident’s trauma informed care assessment showed the resident experienced a traumatic event, had nightmares, avoided reminders, felt numb or detached, and felt guilty. Psychiatric notes documented a history of physical and sexual abuse, substance abuse, and increased irritability and yelling at staff. During observation and interview, the resident appeared fidgety and anxious, avoided eye contact, became quiet when discussing the past, and stated that loud people were triggering and that nightmares occurred sometimes. The care plan did not include goals for psychosocial or mental health needs, trauma history, triggers, or non-pharmacological interventions. A second resident with PTSD and schizoaffective disorder bipolar type had an order for prazosin for nightmares, but the care plan did not address trauma history, triggers, behaviors, goals for psychosocial or mental health needs, or non-pharmacological interventions. During observation and interview, the resident was tearful, fidgety, and anxious while discussing nightmares, church leaders, mental health providers, and police, and stated that bad dreams were recurring, some resident behaviors were triggering, and that someone to talk to about triggers would help. A third resident with PTSD, anxiety, bipolar disorder, and cognitive impairment had psychotropic medications ordered for mood and PTSD, but the care plan did not address trauma history or triggers. During observation, the resident was very distracted, fidgety, and had rapid mood changes during conversation. Staff interviews confirmed that PTSD care plans should include triggers and non-pharmacological interventions, but the three residents’ plans did not reflect those needs.
Failure to Identify PTSD Triggers in Care Plans
Penalty
Summary
The facility failed to ensure that residents with PTSD received care and services that addressed their psychosocial needs. Surveyors found this affected two residents reviewed for trauma-informed care, both of whom had diagnoses that included PTSD along with multiple other medical and psychiatric conditions. The facility record review and staff interviews showed that the residents’ care plans included general behavioral health and psychosocial interventions, but did not identify specific PTSD triggers or document a trauma-informed assessment related to their histories. For one resident, the record showed an admission with diagnoses including COPD, asthma, pulmonary embolism without acute cor pulmonale, and PTSD. The quarterly MDS indicated intact cognition and PTSD, and the care plan included interventions such as behavioral health consults, monitoring for mood changes or distress, providing a calm safe environment, and encouraging expression of feelings. However, there was no documentation of identified PTSD triggers in the care plan, and the PTSD assessment was not completed until later, still without written triggers. The Director of Social Services confirmed that no trauma-informed care assessment related to PTSD triggers had been completed. For the other resident, the record showed a long-term admission history with diagnoses including paraplegia, diabetes, schizoaffective disorder, bipolar disorder, major depressive disorder, generalized anxiety disorder, intellectual disabilities, dysphagia, and PTSD. The care plan addressed impaired psychiatric and mood status and psychosocial wellbeing, but it did not mention specific trauma triggers or trauma history. Staff interviews showed they did not know the resident’s triggers, and one LPN reported behaviors such as picking at the colostomy bag and eating scabs, while a CNA said the resident cried frequently and cried when told what to do. The CPA confirmed she was unaware of the ongoing behaviors, did not know the resident’s triggers or trauma history, and stated that if she had known the behaviors were chronic she would have considered additional psychiatric diagnoses and talk therapy.
Failure to Assess PTSD Triggers and Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure a resident with PTSD received timely assessment and trauma-informed care after readmission. The resident had diagnoses including heart failure and PTSD, with a prior social services assessment noting PTSD related to military service and coping mechanisms that included trying not to think about it and attending a PTSD support group. No revised assessment related to the resident’s PTSD was found in the clinical record after the earlier admission, and upon readmission the social services assessment did not address PTSD, triggers, or coping mechanisms. The quarterly MDS showed the resident was cognitively intact with a BIMS score of 15. The revised care plan later identified a sad or depressed mood related to PTSD and possible flashbacks of violent wartime events, and noted attendance at a veteran support group with family transportation, but it did not identify loud noises as a trigger. During observation, the resident became agitated when asked about trauma triggers and stated that loud noises and noises from the neighboring room bothered the resident. Staff interviews showed multiple staff were aware of the resident’s noise-related anxiety and complaints, but the concerns were not documented as behaviors, the resident was not recently interviewed about PTSD needs on readmission, and the updated care plan was based on an outdated social services assessment. Staff also acknowledged newly identified triggers were not incorporated into the care plan and that the resident’s repeated complaints about noise were signs of agitation that should have been documented.
Missing Trauma Assessments and Incomplete Trauma-Informed Care Planning
Penalty
Summary
The facility failed to ensure that residents with trauma histories received trauma-informed and culturally competent care. For one resident, the record showed admission diagnoses including high blood pressure, cognitive impairment following cerebrovascular disease, and GERD. Her admission MDS indicated severely impaired cognition, and her baseline care plan did not include any past trauma or triggers. The trauma-informed care assessment stated the social worker was unable to determine whether she had experienced any traumatic event, and the social history did not identify trauma or triggers even though it was completed with the resident and a family member. During interviews, staff stated they were aware that this resident had prior trauma related to a group of men breaking into her house and that being confined and men triggered her behaviors. The hospice RN said floor staff had been notified on admission that she had been attacked in her home by a group of men and that men triggered her. The social worker stated a family member had reported childhood teasing and the prior attack by a group of men, and said this information should have been included in the assessment record and care plan, but it was not provided. The DON and Administrator stated their expectation was that the social worker obtain the information, document trauma and triggers, and include them in the baseline care plan. For a second resident, the record showed diagnoses including PTSD, anxiety, and COPD, and the MDS indicated intact cognition and a diagnosis of PTSD. The medical record did not contain a trauma assessment or trauma screen. The comprehensive care plan addressed behavioral problems related to mental illness and PTSD, but the trauma assessment itself was missing. The DON stated she could not find the trauma assessment and believed it had not been done. The social worker stated she was responsible for trauma assessments, was aware of reported sexual trauma prior to admission, and said the facility had not been doing trauma assessments when she was first hired. She also stated that trauma assessments were being done for new admissions and certain readmissions, and that the purpose was to identify trauma and triggers so a plan of care could be developed to reduce recurrence.
Failure to Provide Trauma-Informed Care by Not Identifying PTSD Triggers
Penalty
Summary
The facility failed to provide trauma informed care for two residents with PTSD by not identifying and documenting specific triggers in their care plans. Facility policy stated that residents with a history of trauma should have triggers identified and care plan interventions developed to minimize or eliminate the effect of those triggers. Resident R1’s record showed diagnoses of PTSD, depression, and dysphagia, and the care plan noted PTSD due to sexual abuse, but it did not identify triggers. A psychiatry note stated to continue to offer support and care plan for triggers when identified, and listed a trigger as a resident who looks like the person who assaulted him, but no description of the assailant was provided. Staff interviews confirmed that the facility had not identified or care planned R1’s PTSD triggers. Resident R33’s record showed diagnoses including COPD, alcohol use, hypertension, and PTSD. His psychiatric note stated he had no recent PTSD symptoms, and his care plan identified PTSD related to past trauma and anxiety, but did not list specific PTSD triggers. During staff interviews, one LPN stated there was nothing about PTSD beyond psychotropic medications, and the RNAC stated that R33 gets anxious when needs are not met. The DON and NHA were informed that the PTSD care plan was not specific to R33’s behavioral triggers as required.
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