Failure to Revise Trauma-Informed Care Plan After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan in a timely manner following a verbal altercation. The resident had documented diagnoses of severe recurrent major depressive disorder, neurocognitive deficits, PTSD, and major depressive disorder, recurrent episode, moderate. The resident’s ADL care plan identified her as at risk for decreased cognition related to PTSD and MDD, directed staff to monitor for emotional distress or mood and behavior changes, implement safety monitoring as needed, and utilize trauma-informed care. The care plan also identified specific triggers, including unannounced visitors, no male attendees, nightmares, and flashbacks. On the date of the incident, an alleged incident report documented that the resident was involved in a verbal altercation with another resident who became visibly upset, raised his voice, and continued yelling in the hallway, requiring staff intervention. Following this altercation, there was no evidence that the facility reviewed or revised the resident’s comprehensive care plan to address updated triggers, supervision needs, conflict-prevention strategies, or psychosocial follow-up. There was no documentation of a care plan meeting or IDT review after the incident. The resident later reported not feeling safe because people continued entering her room without knocking and stated that the other resident’s behavior triggered her PTSD and caused fear for her safety. The other resident reported a different account of the interaction and continued to knock and open the door slightly after the incident. A nursing assistant reported not recalling recent education on trauma-informed care and was unaware of any recent review of the resident’s care plan. The unit manager RN acknowledged that she did not update the care plan with new interventions after the altercation, and the DON stated the care plan should have been reviewed and revised after such an incident. The facility’s Trauma Informed Care policy required adding goals and interventions to the care plan for residents with a history of trauma and updating the care plan as needed, which was not done in this case.
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