Failure to develop a trauma-informed care plan for a resident with PTSD and a traumatic life event. The resident’s social service assessment documented PTSD and a traumatic accident, but the comprehensive care plan did not include the history or individualized interventions. A CNA was unaware of any PTSD-related triggers or restrictions, and the SW and DON acknowledged the resident did not have a care plan specific to PTSD or the traumatic event.
Failure to identify PTSD triggers and trauma-informed interventions for a resident with PTSD, major depression, and a recent knee replacement. The resident was cognitively intact, but the care plan did not document triggers, mitigation interventions, or whether the resident refused to discuss PTSD or had no known triggers. Social services notes and the medical record also did not show that PTSD or potential triggers were assessed, and the resident reported that staff loud talking at night could trigger memories of childhood living situations.
Failure to update a trauma care plan after a resident reported sexual abuse by another resident. The resident, who had anxiety, depression, and paraplegia, said the other resident repeatedly made vulgar sexual threats and that the issue had been reported to the DON and NHA and even involved police. The trauma plan remained focused on an older trauma history and loud-noise triggers, and staff interviews confirmed the plan was not updated to address the resident’s fear and the ongoing peer abuse.
A resident with PTSD and severe cognitive impairment did not have a trauma assessment completed on admission, and the PTSD care plan remained generic rather than person-centered. The SW and Corporate Nurse stated the assessment should have been completed in the EHR and used to build individualized interventions to address the resident’s trauma and triggers.
Failure to Develop Trauma-Informed Care Plan: A resident with substance use disorder and cognitive impairment was observed scared and asking for help, while the care plan addressed behavioral symptoms but did not reflect a documented trauma history. The LMHC noted trauma related to drug use, living on the streets, and physical abuse, but the SS eval recorded no upsetting trauma experience and did not show further inquiry or individualized trauma-informed interventions.
Failure to assess trauma and identify triggers for a resident with PTSD: A resident with a history of military service, PTSD, and moderate cognitive impairment reacted to loud noises by trying to stand up and saying he/she did not like loud noises and to stop yelling. Notes also documented anxiety, fear that everyone would die, and concern about an explosion. The record showed no completed trauma assessment, no identified triggers, and no trauma-related care plan, and staff said they had not completed the assessment or linked the resident’s behaviors to possible trauma.
Failure to complete trauma screening and PTSD care planning: A resident with schizophrenia, bipolar disorder, and PTSD had no completed trauma assessment in the record, and the care plan did not identify specific triggers for re-traumatization. Staff interviews showed the trauma questionnaire was attempted only once, the RN was unaware of PTSD concerns or triggers, and the DON stated residents with PTSD need timely assessments and individualized care plans with triggers known to staff.
Failure to Develop Person-Centered PTSD Care Plans: Two residents with PTSD had care plans that did not identify their specific trauma histories, triggers, or signs and symptoms of trauma. Record review showed one resident had nightmares, flashbacks, sexual assault history, and domestic violence concerns, while the other had extensive trauma including childhood abuse, foster care, physical assault, and family loss. The SW and DON stated PTSD care plans should be person centered, and the COO could not locate a trauma informed assessment for either resident.
Failure to care plan for trauma triggers: A resident with anxiety, depression, Alzheimer’s disease, TBI, and PTSD had behavioral symptoms, rejection of care, and wandering, but the care plan did not include the family-reported history of prior assault or the related startle trigger. The resident’s Kardex and CNA care card also lacked this trauma information, and staff interviews confirmed the trigger was not clearly communicated to direct care staff.
Failure to provide trauma-informed care for a resident with a history of childhood sexual abuse. The resident had vascular dementia, depression, anxiety, Parkinson's disease, and behavioral symptoms, but the care plan did not include trauma-informed interventions or identified triggers. Although the PNP documented the abuse history and referred the resident to therapy, the SW was not aware of the history and the interdisciplinary team was not notified of each behavioral health encounter.
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