Failure to Develop and Implement Individualized Trauma-Informed Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement an individualized, comprehensive, resident-centered care plan for a resident identified as having trauma. The resident had a history of chronic medical conditions, including COPD, alcoholic polyneuropathy, alcoholic cirrhosis with ascites, type 2 diabetes, and respiratory failure with hypoxia. Despite quarterly assessments indicating the resident experienced trauma related to life-threatening illness and exposure to combat and captivity, the resident's diagnoses list did not include a trauma-related diagnosis, and the care plan lacked resident-specific trauma interventions. The care plan in place contained general statements and non-specific interventions, such as determining triggers and de-escalation preferences, providing a safe environment, and referring to psychology as indicated. However, it did not specify the resident's actual trauma triggers or preferred interventions, even though the resident had communicated these during assessments. Staff interviews revealed that multiple team members, including RNs, CNAs, the DON, the Unit Manager, the MDS Coordinator, and the Social Services Coordinator, were unaware of the resident's trauma history, triggers, or specific interventions. Staff consistently stated that care plans should be personalized and include specific triggers and interventions to guide care, but this was not done for the resident in question. An incident occurred in which the resident was physically assaulted by another resident, resulting in significant distress and ongoing upset for the affected resident. Staff were not aware of how to respond to the resident's trauma or triggers following the incident, as the care plan did not provide the necessary individualized information. The Social Services Coordinator, who had signed off on the trauma assessments, acknowledged that the care plan should have been edited to include the resident's specific trauma and triggers but had not done so. This lack of individualized planning and communication led to staff being unprepared to meet the resident's trauma-related needs.