Failure to Assess and Care Plan for Resident with PTSD
Summary
Surveyors identified that the facility failed to provide trauma-informed, person-centered care for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with PTSD, depression, polyneuropathy, and insomnia, and a Minimum Data Set assessment showed no cognitive impairment, a need for substantial assistance with activities of daily living, and a confirmed PTSD diagnosis. Despite this, the clinical record contained no documentation that the resident had been assessed for PTSD-related symptoms or triggers, and the resident’s care plan lacked any measures addressing the history of trauma, identifying triggers, or specifying interventions to minimize triggers or re-traumatization. In an interview, the Director of Nursing confirmed that the resident had not been assessed or care planned for PTSD, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with schizophrenia, anxiety, and PTSD reported a preference for female staff only for bathing and personal care due to past sexual assault trauma, but the care plan did not identify this preference or PTSD triggers. The resident said staff had to be reminded weekly, and a CNA confirmed the preference for female staff because of past trauma.
Surveyors found that the facility failed to complete required trauma-informed assessments for three residents with histories of traumatic events and multiple medical conditions, including dementia, osteoporosis, chronic pain, and advanced physical debility. In each case, an Annually/Quarterly Trauma Evaluation form was present, but the Staff Assessment section—intended to document changes in sleep, appetite, behavior in specific situations, caregiver preference, and new pain or health complaints—was left blank, with no licensed nurse documentation, despite care plan directives for person-centered trauma evaluations and the ADON’s acknowledgment that licensed nurses are responsible for completing these assessments.
Two residents with PTSD and major depressive disorder did not receive adequate trauma-informed care when the facility failed to identify and document their specific trauma-related triggers and did not ensure follow-up mental health services. In both cases, trauma-informed care assessments showed that the residents had experienced trauma and reported distressing memories, dreams, and other PTSD-related symptoms, and their care plans broadly referenced potential behaviors related to past trauma with an intervention to identify triggers. However, the plans did not include resident-specific traumas or triggers, and one resident did not receive a psychiatry consult despite a physician order and consent, while the other had no documented follow-up related to PTSD, as confirmed by the NHA and DON.
Failure to identify PTSD triggers in a resident’s care plan. A resident with PTSD, HTN, and insomnia had a care plan that noted a traumatic event but did not identify any PTSD-related triggers, despite the facility policy requiring trigger identification and trigger-specific interventions to reduce retraumatization. The SW confirmed the lapse during interview.
Two residents with documented PTSD and other behavioral health diagnoses did not receive trauma‑informed care because the facility failed to complete trauma assessments, identify PTSD triggers, or develop individualized interventions. One resident with PTSD, dementia, anxiety, bipolar and mood disorder had a care plan listing behaviors such as yelling, hitting, refusals, and sexually inappropriate conduct, but the plan lacked any PTSD triggers or specific strategies to manage them, and her EMR contained no trauma‑informed assessment. Another resident with PTSD, depressive disorder, TBI, and panic disorder received multiple psychotropic medications, yet had no documented trauma assessment or triggers, and staff from nursing, social services, and CMA roles all reported they did not know his PTSD triggers and confirmed they were not on the care plan, contrary to the facility’s behavioral health policy.
Surveyors found that the facility failed to identify and document trauma triggers in the care plans of two residents with PTSD. One resident with dementia and severe cognitive impairment had a trauma history noted but no triggers listed on the trauma care plan, and no social services re-evaluation was completed after a prior assessment despite the MDS continuing to show PTSD as an active diagnosis. Another resident with depression and PTSD related to Vietnam War service had a trauma evaluation and social services assessment documenting nightmares, difficulty sleeping, and specific triggers of loud noises and enclosed spaces, yet the active trauma care plan only contained vague language and an incomplete intervention to "avoid (specify)" without listing those triggers.
Failure to Honor Resident Preference for Female Staff During Personal Care
Penalty
Summary
The facility failed to ensure that one resident with a BIMS score of 13, diagnoses of schizophrenia, anxiety, and PTSD, received care that accounted for personal preferences intended to reduce triggers related to past trauma. The resident stated during interview that due to PTSD from a prior sexual assault, the resident requested that men not bathe him/her, and reported having to remind staff weekly of this preference. The care plan dated 1/23/26 did not identify the resident's preference for female staff only for personalized care, ADLs, and bathing, and did not identify PTSD triggers or the preference for only female staff to assist with bathing. A CNA confirmed that the resident preferred female staff because of past trauma.
Incomplete Trauma-Informed Assessments for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure residents were comprehensively assessed for a history of trauma, including identification of trauma-related triggers, for three residents whose records were reviewed for trauma-informed care. For a resident with anemia, moderate dementia, chronic pain, and a documented history of sexual assault who reported feeling safe in the facility, the care plan did not document the need for an annual trauma evaluation. Although an Annually/Quarterly Trauma Evaluation form dated 4/24/26 was present in the record, the Staff Assessment section—intended to capture changes in sleep, appetite, behavioral patterns in response to specific situations, caregiver preference, and new complaints of pain or health problems—was left blank, with no documentation completed by a licensed nurse. A second resident with age-related osteoporosis, chronic pain, and a left hip fracture had a care plan noting reported traumatic events and a directive that licensed nursing staff complete a person-centered trauma evaluation annually per resident preference. An Annually/Quarterly Trauma Evaluation form dated 4/28/26 was found in this resident’s record, but the Staff Assessment section was also blank, with no licensed nurse documentation. A third resident with advanced physical debility, chronic pain, and chronic bilateral hand tremors had a care plan directing completion of a person-centered trauma evaluation annually, after a fall, or with a significant change, and documenting the resident’s request not to be evaluated quarterly. An Annually/Quarterly Trauma Evaluation form dated 1/27/26 was present, but again the Staff Assessment section was blank with no licensed nurse documentation. The ADON stated that trauma evaluations should be completed and confirmed that licensed nurses are responsible for documenting the assessment and determination.
Failure to Provide Trauma-Informed Care and Identify PTSD Triggers
Penalty
Summary
The facility failed to provide trauma-informed, culturally competent care to residents with PTSD and related mental health diagnoses by not identifying resident-specific trauma triggers and not ensuring timely psychiatric services. For one resident with PTSD, anxiety disorder, and major depressive disorder, the trauma-informed care assessment documented that the resident had experienced trauma and reported feeling very upset when reminded of the stressful experience, feeling jumpy or easily startled, and having trouble falling or staying asleep. The comprehensive care plan included a focus on potential behaviors related to past trauma due to childhood abuse and an intervention to identify potential triggers, but the record did not contain any documentation of the resident’s specific triggers. Additionally, although there was a physician’s order for a psychiatry consult and consent from the resident’s representative, the clinical record contained no documentation that the consult had occurred, and the DON confirmed that the resident had not received psychiatric services. For a second resident with PTSD and major depressive disorder, the trauma-informed care assessment showed that the resident had experienced trauma and reported repeated, disturbing and unwanted memories of the stressful event and disturbing dreams of the stressful experience. The comprehensive care plan included a focus on potential behaviors related to past trauma with an intervention to identify potential triggers, but the plan did not specify the resident’s particular trauma or any identified triggers. The clinical record also lacked any follow-up related to the resident’s PTSD, and during interviews, the NHA and DON stated that the facility had no additional information regarding this resident’s PTSD. The DON acknowledged that the facility’s expectation was that trauma and triggers be identified and that residents receive trauma-informed care, but this had not occurred for these two residents.
Failure to Identify PTSD Triggers in Care Plan
Penalty
Summary
The facility failed to provide trauma informed care for Resident R43, who had a diagnosis of PTSD, high blood pressure, and insomnia. Review of the facility’s Trauma Informed Care policy showed that the facility was to identify triggers that may retraumatize residents with a history of trauma and add trigger-specific interventions to the care plan to decrease exposure to those triggers or mitigate their effects. However, review of Resident R43’s care plan for PTSD showed that it identified a traumatic event but did not identify any triggers related to PTSD. During an interview, the Social Worker confirmed that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization for Resident R43.
Failure to Identify PTSD Triggers and Implement Trauma‑Informed Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide trauma‑informed and culturally competent care by not identifying PTSD triggers or developing individualized interventions for two residents with documented PTSD and other behavioral health diagnoses. One resident had PTSD, dementia, anxiety, bipolar and mood disorder, and was care planned for behavioral symptoms such as yelling at staff, hitting, refusal of medications and treatment, refusal of meals, and sexually inappropriate behavior. Her care plan directed staff to administer medications as ordered, notify the physician of inappropriate behavior, and allow her to express herself, but it did not identify any PTSD triggers or specify how staff should manage those triggers. Her EMR also lacked any trauma‑informed care assessment, despite her intact cognition and dependence in ADLs. For this same resident, physician orders included antipsychotic medication (Latuda) for schizophrenia, and nursing documentation noted a history of mental and behavioral disorders and that she was upset after a care plan meeting where she was told she had schizophrenia and underlying mental health conditions. Administrative nursing staff confirmed that resident‑specific interventions had not been developed to address her PTSD diagnosis upon admission. This was inconsistent with the facility’s Behavioral Health Services policy, which stated that behavioral health services, including trauma‑informed care related to history of trauma and PTSD, would be provided as part of an interdisciplinary, person‑centered approach. The second resident’s EMR documented PTSD, depressive disorder, traumatic brain injury, and panic disorder, with intact cognition and partial assistance needs for certain ADLs. The resident received multiple psychotropic medications, including antipsychotics and an antidepressant, for PTSD, depressive disorder, and TBI‑related PTSD. However, the EMR lacked a trauma‑informed assessment with identified triggers, and the care plan only noted potential for behaviors due to PTSD, depression, and panic disorder, with general interventions such as administering medications, providing positive interactions, explaining procedures, allowing adjustment to changes, and monitoring for behaviors. A CMA, social services staff, and a nurse each stated they were unaware of any PTSD triggers for this resident, and confirmed that no PTSD triggers were listed on the care plan. Administrative nursing staff acknowledged that a trauma assessment had not been completed as expected under the facility’s Behavioral Health Services policy, which required behavioral health and trauma‑informed services in accordance with the comprehensive assessment and plan of care.
Failure to Identify and Document PTSD Trauma Triggers in Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to provide trauma-informed care by identifying and documenting trauma triggers on care plans for residents with PTSD, as required by regulation and facility policy. For one resident with Alzheimer’s disease, dementia, major depressive disorder, PTSD, and severe cognitive impairment, the trauma care plan initiated in mid-2023 noted a past abusive relationship as a trauma history but did not identify any specific trauma triggers. Social services re-evaluations completed in 2025 repeatedly documented that the resident had not suffered from PTSD since the last assessment, but there was no subsequent social services re-evaluation after November 2025 despite the quarterly MDS in January 2026 listing PTSD as an active diagnosis. The social services worker confirmed that no triggers were identified on the care plan and there was no documentation that the resident denied having triggers, and also confirmed the absence of a required re-evaluation after November 2025. For a second resident admitted in early 2026 with major depressive disorder and later-documented PTSD, the facility completed a trauma evaluation that recorded affirmative responses to questions about experiencing a frightening or traumatic event and having unwanted thoughts or nightmares about it, but the form did not explain what the resulting score meant and contained no additional comments. The resident was hospitalized for pneumonia and, during that hospitalization, PTSD was listed as an active diagnosis treated with Effexor. Upon readmission, the attending physician and a subsequent social services re-evaluation both documented PTSD as an active diagnosis, with the social services assessment specifying that the PTSD was related to Vietnam War service, that the resident had difficulty sleeping almost every night, and that loud noises and closed spaces were identified as triggers. Despite this information, the resident’s active trauma care plan only generally stated that he had experienced trauma in the past, that his PTSD was from the Vietnam War, and that he was followed by VA psychiatric services. The care plan described possible trauma expressions such as hypervigilance, social isolation, and flashbacks, and included goals related to feeling safe and not being re-traumatized, but the interventions section merely stated to avoid “(specify)” without listing the known triggers. During an interview, the resident confirmed that loud or sudden noises and enclosed spaces were triggers and described his reaction when triggered, yet these specific triggers were not incorporated into the trauma-informed care plan until the day of the survey, contrary to the facility’s policy requiring that identified trauma and triggers be addressed in the care plan and that social services re-evaluations be completed with each MDS or at least every 90 days.
Plan Of Correction
1. On 4/14/26 the Social Service Designee reviewed resident #78's Trauma Care Plan and updated it to indicate no identified triggers for PTSD. A social service re-evaluation was completed on 4/24/26 by the Social Service Director at which time the resident denied any trauma. On 4/28/26 the Social Service Designee reviewed resident #109's Trauma Care Plan and updated it to include identified triggers for PTSD. 2. Like Residents are identified as residents who have a history of trauma. Utilizing the Trauma Informed Care Audit Tool, which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of identified residents will be completed by the Social Services Designee to ensure the SS evaluation accurately identifies PTSD and they have identified trauma triggers listed on their trauma care plan. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Administrator or designee will re-educate the Social Services department on the Social Services Documentation Policy to include evaluating trauma and care planning triggers for residents with a history of trauma. This education will be completed on or before 5/13/26. 4. Utilizing the Trauma Informed Care Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit admissions, readmissions and residents due for quarterly assessments weekly for four weeks beginning 5/14/26 to ensure the SS evaluation identifies those with PTSD diagnosis and that trauma triggers are listed on their trauma care plan. Noncompliance noted from audits will be corrected with residents reassessed and care plans revised as indicated. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
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