Failure to Provide Trauma-Informed Care and Identify PTSD Triggers
Penalty
Summary
The deficiency involves the facility’s failure to provide trauma-informed care by identifying and addressing trauma-related triggers for residents with PTSD, as required by its own policies and care planning processes. For one resident with PTSD and dementia, the MDS and social service assessments documented behavioral symptoms such as verbal and physical behaviors toward others, rejection of care, and socially inappropriate behaviors, as well as identified triggers like distress when others "mess with my stuff" and calming strategies such as talking things out and preferred activities. An LPN reported that male staff were a known trigger for this resident and that staff attempted to limit male caregivers and use redirection when the resident became upset. However, the comprehensive care plan, while listing PTSD as a diagnosis, did not include male caregivers as a trauma-related trigger or any trigger-specific, trauma-informed interventions or staff approaches related to this known trigger, contrary to the facility’s Comprehensive Care Plans policy. For another resident, admission documentation from a Veterans Affairs facility identified PTSD as a diagnosis, and the care plan referenced impaired mood and psychiatric status related to PTSD. Despite this, the facility’s Trauma-Informed Care assessment incorrectly marked PTSD as "No," and social services assessments did not identify PTSD or document any trauma history. The medical record lacked evidence that trauma-related triggers were assessed or identified, and there were no individualized trauma-informed interventions implemented. The Social Services Director stated that when a resident has a PTSD diagnosis, the expectation is that trauma history and PTSD-related triggers are assessed, documented, and communicated to the interdisciplinary team, as required by the facility’s Trauma-Informed Care policy, but this had not occurred for this resident. A third resident had a long-standing diagnosis of PTSD along with quadriplegia, reduced mobility, insomnia, generalized anxiety, major depressive disorder, and chronic pain syndrome. The care plan identified risk for impaired mood and psychiatric status related to depression, PTSD, and anxiety, with general psychosocial interventions such as discussing solutions to conflict, observing for mood changes, and encouraging expression of feelings. Social service progress reviews over several months documented that the resident had PTSD, reported symptoms were being managed effectively, and that the facility had not identified any known triggers. A mental health visit later documented chronic PTSD with increased depression, poor sleep, and nightmares, and an antidepressant was ordered for insomnia. In a subsequent interview, the resident reported PTSD was poorly managed, with persistent night terrors and significantly reduced sleep, and expressed interest in working with social services to manage PTSD and identify possible triggers. The Social Services Director confirmed there were no documented triggers in the social service notes or care plan, and an LPN was unaware of any PTSD triggers for this resident, while the DON acknowledged that PTSD diagnoses should have triggers identified and monitored in the care plan. This series of omissions demonstrated the facility’s failure to identify and document trauma-related triggers and integrate them into care planning for residents with PTSD.
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