Failure to Assess and Care Plan PTSD Triggers Leading to Resident‑to‑Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate behavioral health treatment and services, including trauma‑informed care, to a resident with diagnosed mental disorders and PTSD. The resident was admitted with traumatic brain injury, PTSD, bipolar disorder, and Alzheimer’s dementia. Hospital discharge instructions included a safety plan that identified a specific personal red flag: the resident becomes angry or aggravated when people are perceived as stealing from him. Despite this, the facility did not complete a PTSD‑specific assessment to identify individualized triggers, and the written care plans for psychosocial, mood, and behavioral issues remained generic and non‑resident‑specific. Multiple documented incidents show the resident’s aggression toward other residents in situations consistent with his known concerns about theft and control. In one incident, the resident pushed another resident standing near the food cart, causing that resident to lose balance and fall. In another, the resident approached a resident seated in a wheelchair in the dining room, attempted to pull the wheelchair backward, and then struck the resident in the face without apparent provocation. In a third incident, the resident yelled at another resident in the hallway and grabbed his arm; before staff could intervene, the other resident struck him, causing him to fall to the floor. Staff interviews revealed that the resident was triggered when other residents went into his room or closet, wore his clothing, were near the food carts, or were yelling, and that he was preoccupied with thoughts of theft and believed others were stealing from him. The resident’s care plans for PTSD, mood disorder, and behavior referenced broad interventions such as avoiding triggers, helping the resident identify triggers, documenting behavioral episodes, and observing for potential triggers, but did not list the specific, known triggers identified by staff and in prior documentation. Care plans created after each altercation only directed staff to observe and document changes in behavior and potential triggers, again without naming the resident’s known triggers. Several staff members, including CNAs and a nurse, stated they were not aware of the resident’s PTSD diagnosis or specific behavioral triggers, even though they acknowledged that all staff should know these triggers to prevent aggression. The resident was also observed wearing medical tape on his jacket labeling himself as an LVN, and multiple staff members stated this was unsafe and could empower him or cause other residents to approach him as if he were staff, potentially contributing to aggressive responses. The facility’s own policies on trauma‑informed care and behavioral assessment required trauma screening, identification of triggers, and individualized care plans, but the resident’s record lacked a PTSD assessment and did not contain resident‑specific triggers or interventions addressing his behavior.
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