Failure to Assess and Address Trauma Triggers for Resident with PTSD
Penalty
Summary
The facility failed to conduct a trauma-informed care assessment for a resident diagnosed with post-traumatic stress disorder (PTSD). During observations, the resident was found alone in their bathroom, screaming and yelling obscenities, and expressed distress when approached. Staff indicated that this behavior was not unusual for the resident. Record review showed that the resident's care plan addressed mood problems related to anxiety, PTSD, and a history of passive suicidal ideation, but did not include any assessment of trauma, identification of possible triggers, or interventions to manage PTSD or prevent re-traumatization. The social worker confirmed that no trauma assessment or trigger evaluation had been completed for the resident, and that the care plan did not address these issues, stating that residents already in-house at the time trauma-informed care became a focus were not assessed.