Failure to Care Plan for PTSD Triggers and Trauma-Informed Strategies
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s post-traumatic stress disorder (PTSD) triggers. The resident was admitted with a documented diagnosis of PTSD and had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. A Social Service Progress Review documented multiple behavioral symptoms, including physical and verbal behaviors directed toward others, rejection of care, and socially inappropriate behaviors. The same assessment identified specific triggers, such as “people messing with my stuff,” and calming strategies including talking things out and engaging in preferred activities, as well as trauma history and completion of trauma-informed care screening. Despite these identified needs and triggers, review of the resident’s care plan showed no interventions addressing PTSD-related triggers, no staff approaches to avoid known triggers, no trauma-informed strategies specific to those triggers, and no documentation to communicate these triggers to direct care staff. During interviews, an LPN reported that male staff were a known trigger for the resident and that staff attempted to limit male caregivers and use redirection and verbal engagement when the resident became upset. The Social Services Director acknowledged awareness that the resident was frequently involved in incidents requiring redirection and confirmed that the resident’s triggers were not documented in the care plan, even though facility policy required comprehensive care plans with measurable objectives and timeframes for identified medical, nursing, mental, and psychosocial needs.
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