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.
Two residents with PTSD and significant trauma histories did not have person-centered care plans addressing their trauma, triggers, or history of suicide attempt. Despite documented histories of abuse, violence, and psychiatric diagnoses, the facility's assessments and care plans failed to identify or address these needs, as confirmed by staff interviews.
A resident with PTSD and dementia did not have a trauma-informed care plan or identified triggers, despite facility policy and assessment findings indicating the need. The responsible social worker had not completed the care plan, and the administrator acknowledged the expectation for such plans to be in place for residents with PTSD.
A resident with PTSD, anxiety, depression, and OCD did not receive a comprehensive trauma assessment or individualized care planning to address their trauma history and triggers. Despite psychiatric documentation of significant trauma, the facility failed to incorporate this information into the care plan or provide specific interventions, and staff interviews revealed confusion about responsibility for trauma-informed care.
A resident with PTSD, vascular dementia, and anxiety did not have a trauma-informed care plan with identified triggers, as required by facility policy. Despite staff expectations that trauma assessments and individualized care plans would be developed collaboratively, the resident's record lacked documentation of such a plan or interventions addressing trauma triggers.
A resident with PTSD and moderate cognitive impairment was admitted without a trauma assessment to identify potential triggers, and the care plan did not include individualized trauma-related interventions. Staff interviews confirmed that required trauma evaluations were not completed on admission or during quarterly reviews, and the health care proxy was not consulted despite the resident's cognitive limitations.
A resident with PTSD and other mental health diagnoses did not have a comprehensive trauma-informed care plan, including identification of triggers, due to the absence of a social worker responsible for completing trauma assessments and care plans. Nursing staff and the DON confirmed that no trauma assessment or individualized PTSD care plan was present in the resident's record.
Two residents with significant trauma histories did not receive required Social Service or trauma assessments, and their care plans lacked individualized trauma-informed interventions. The Social Worker was aware of the residents' trauma backgrounds but did not complete or document assessments or update care plans, resulting in overdue Social Service assessments and non-compliance with facility policy.
A resident with PTSD and other complex diagnoses did not have a personalized care plan that addressed their specific traumatic experiences or included interventions to mitigate triggers, despite facility policy requiring trauma-informed care. The care plans referenced PTSD but lacked individualized details and strategies, and the Social Worker confirmed the absence of a personalized approach.
A resident with PTSD, anxiety, and depression was not assessed for trauma history or potential triggers, and no individualized care plan was developed to address these needs. Staff, including the Director of Social Services, acknowledged the oversight, and documentation lacked details or interventions to prevent re-traumatization, contrary to facility policy.
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