Failure to Incorporate Known Trauma Trigger and Care Preference Into Care Plan
Penalty
Summary
The facility failed to provide trauma-informed, culturally competent care by not incorporating a known trauma trigger and related preference into a resident’s care plan. Facility policy on Trauma Informed Care and Culturally Competent Care required the center to identify triggers that may re-traumatize patients with a history of trauma and to add trigger-specific interventions to the care plan to decrease exposure and mitigate effects. The resident’s diagnoses included PTSD and major depressive disorder. Psychiatry notes from two visits documented that the resident had a trauma history of childhood abuse by stepfathers and a stated preference to not have male caregivers. Despite this information, review of the resident’s care plan, initiated for risk of distressed/fluctuating mood symptoms related to anxiety and PTSD, did not include any intervention reflecting the resident’s preference to avoid male caregivers or any identified trauma triggers. A trauma assessment completed later showed a positive trauma screen with a score of 4, but the care plan still lacked documentation of the trigger or related interventions. In an interview, the Nursing Home Administrator stated he would have expected the resident’s trigger of male caregivers to have been added to the care plan and in place, confirming that this had not occurred.
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