Failure to Complete Trauma-Informed Assessment for Resident with PTSD
Summary
The facility failed to adequately assess a resident with a diagnosis of post-traumatic stress disorder (PTSD) for trauma triggers and effective interventions to prevent re-traumatization. Upon admission, the resident was cognitively intact and had a history of PTSD, anxiety, depression, and a recent fall with fracture. The admission Minimum Data Set (MDS) indicated the resident required substantial assistance with activities of daily living and was always incontinent. The facility's Trauma-Informed Care Observation form for this resident was incomplete, with several key questions about traumatic experiences, emotional impact, triggers, and coping strategies left unanswered. The resident's care plan included goals and interventions related to trauma and PTSD, such as identifying triggers and utilizing coping strategies, but the necessary assessment to inform these interventions was not completed. Interviews with facility staff, including the Social Services Coordinator and Regional Nurse, confirmed that the trauma-informed care assessment was not fully completed as required by facility policy. The facility policy stated that all residents should be assessed for a history of trauma upon admission using the designated observation tool, which was not done in this case.
Penalty
Resources
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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.
The facility failed to provide trauma-informed care by not consistently identifying, documenting, or care-planning for PTSD-related triggers in three residents with PTSD. One resident with dementia and PTSD had known behavioral symptoms and a known trigger related to male caregivers, acknowledged by an LPN, but this trigger and related interventions were not included in the care plan. Another resident admitted with a documented PTSD diagnosis from a VA source had PTSD incorrectly marked as absent on the trauma-informed care assessment, with no trauma history, triggers, or individualized interventions documented by social services. A third resident with PTSD, depression, anxiety, insomnia, and quadriplegia had general psychosocial interventions in the care plan, but repeated social service notes stated no triggers were identified, despite later reports of worsening depression, nightmares, and poor sleep; staff, including an LPN and the DON, confirmed that PTSD triggers were neither identified nor incorporated into the care plan.
The facility did not identify PTSD triggers in the care plan for a resident with a known PTSD diagnosis and failed to assess another resident for PTSD despite recent traumatic experiences. Two residents were affected, and the facility's policy requiring trauma-informed care and identification of triggers was not followed.
A resident with dementia and PTSD, who had a history of traumatic experiences and behavioral symptoms, did not receive trauma-informed care as required. The care plan, Kardex, and nursing notes lacked references to trauma or related interventions, and staff were unaware of specific trauma triggers or care needs. Facility policy required trauma assessments and care planning, but these were not completed or reflected in the resident's documentation.
A resident with dementia, anxiety, and depression disclosed a history of childhood sexual abuse and experienced flashbacks and delusions, but staff did not assess for trauma or document triggers and interventions in the care plan or Kardex. Social services and psych providers were not notified or involved in trauma assessment after the resident's disclosure, and staff were unaware of the resident's trauma history or care needs related to trauma. The facility's policy lacked procedures for trauma assessment and care planning.
A resident with PTSD, anxiety, and depression did not receive trauma-informed care, as assessments and care plans lacked documentation of trauma history, triggers, or specific interventions. The resident reported ongoing night terrors and identified triggers, but staff interviews revealed limited awareness of the diagnosis or appropriate interventions.
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.
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.
Failure to Identify and Address PTSD Triggers and Assess for Trauma
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents with significant histories of trauma and mental health concerns. For one resident with diagnoses including PTSD, anxiety disorder, and depression, the care plan did not include specific PTSD triggers, despite documentation in the social services evaluation that identified triggers such as people, thoughts, and feelings. The care plan only addressed general interventions for mood and anxiety but omitted the individualized triggers that could help staff avoid re-traumatization. This omission was confirmed by the social worker during an interview. For another resident with a history of recent traumatic events, including the loss of a child to suicide and a recent bilateral leg amputation, there was no assessment for PTSD upon admission or during the resident's stay. The resident expressed feelings of sadness and depression and requested to speak with someone, but the social service designee was unaware of the resident's traumatic loss and confirmed that no PTSD assessment had been completed. The facility's policy requires trauma to be identified and addressed in the care plan, including triggers and interventions, but this was not done for these residents.
Failure to Provide Trauma-Informed Care for Resident with PTSD and Dementia
Penalty
Summary
The facility failed to provide trauma-informed care to a resident with a history of dementia, major depressive disorder, anxiety disorder, intermittent explosive disorder, alcohol abuse, and post-traumatic stress disorder (PTSD). The resident had documented traumatic experiences, including being assaulted and serving in the Vietnam War, which were noted in psychosocial assessments and family interviews. Despite these documented traumas and ongoing behavioral symptoms such as paranoia, hallucinations, resistance to care, and combativeness, there was no evidence that trauma-specific assessments were completed after admission. The resident's care plan, last reviewed in April 2025, did not reference trauma, trauma triggers, or trauma-informed interventions, even though the resident was dependent on staff for emotional, intellectual, physical, and social needs due to cognitive deficits. The Kardex for nursing assistants and nursing progress notes from June 2024 to June 2025 also lacked any information or documentation relevant to trauma or trauma-informed care. Staff interviews confirmed a lack of knowledge regarding specific trauma-related care or triggers for the resident, and the social services staff reported that no specific trauma assessment was used beyond an initial screening at admission. The facility's policy required assessment and care planning for trauma and behavioral health issues on admission and quarterly, including identification of triggers and non-pharmacological interventions. However, the care plan and supporting documentation did not reflect these requirements for the resident in question, and staff were not able to identify or implement trauma-informed care practices as outlined in the policy.
Failure to Provide Trauma-Informed Care and Assess for Trauma After Resident Disclosure
Penalty
Summary
The facility failed to provide trauma-informed care in accordance with professional standards of practice for a resident with a history of trauma and mental health diagnoses. The resident, admitted with dementia, COPD, anxiety disorder, mood disorder, and depression, reported a history of childhood sexual abuse and experienced flashbacks, hallucinations, and delusions related to this trauma. Despite these disclosures, there was no evidence that the facility's social services or psychiatric providers assessed the resident for trauma following her statements, nor were any trauma-related triggers or interventions documented in her care plan or Kardex. The deficiency was identified after the resident alleged rough treatment by a CNA, which she later recanted, attributing her statements to confusion and flashbacks from past trauma. Multiple assessments and progress notes failed to document any follow-up or trauma assessment after the incident, and staff interviews revealed a lack of awareness regarding the resident's trauma history, triggers, or appropriate interventions. The facility's policy on trauma-informed care did not include procedures for assessing residents for trauma or ensuring that triggers were identified and addressed in the plan of care. Interviews with facility staff, including the administrator, social service designee, CNA, and psychiatric nurse practitioner, confirmed that the resident's trauma history was not communicated or incorporated into her care planning. The lack of documentation and communication resulted in the resident's trauma history and related care needs being unaddressed, despite her ongoing symptoms and requests for therapy related to her flashbacks.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care that considered a resident's history and preferences, specifically for a resident diagnosed with PTSD, anxiety disorder, and depression. The medical record review showed that trauma-related assessments were either marked as not applicable or left blank, and there was no documentation in the social services progress notes addressing the resident's PTSD, its impact on daily living, or any identified triggers and interventions to prevent re-traumatization. The care plan did not include a problem or interventions specific to PTSD, and the only mention of a past traumatic event lacked details about the event, triggers, or person-centered interventions. Interviews with the resident revealed a history of physical abuse leading to PTSD, with specific emotional triggers such as being coerced, having anything wrapped around her, or feeling physically restricted. The resident reported ongoing night terrors while at the facility. Interviews with CNAs indicated a lack of awareness or understanding of the resident's PTSD diagnosis, triggers, or appropriate interventions, with some staff unaware of the diagnosis and others unable to identify or confirm trauma-related interventions. This demonstrates a failure to ensure staff were informed and prepared to provide trauma-informed care tailored to the resident's needs.
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