A 75-year-old female resident reports to her nurse that she has been having nightmares for the past several nights. She has been feeling nervous during the day. She has not eaten in the dining room for several days and instead has been eating at the end of a hallway by herself. She decided not to attend the monthly trip to Walmart this week. 

When she meets with her psychologist, the resident reports that the constant news coverage of the recent mass shooting at Walmart in El Paso, TX, has triggered her symptoms of chronic post-traumatic stress disorder. Although her PTSD is related to childhood sexual trauma, the images of the children shopping to buy school supplies at the time of the shooting are “stuck” in her mind. She has been having flashbacks of her own childhood trauma. She didn’t go to Walmart this week because she feared being killed. 

This example highlights the importance of being aware of a resident’s trauma history and how external events may negatively impact associated emotional and behavioral symptoms.

It highlights the need of having a skilled behavioral health specialist in your facility who can recognize, identify, assess, and treat the sequelae of trauma. In this example, facility staff had not made an association between recent news events and an observed change in the resident’s behavior. Even more unfortunately, the television in the dining room played news coverage of the recent mass shootings during mealtime for several days. 

As of Nov. 28, there will be trauma focused F-tags that surveyors will assess as part of Phase 3 implementation. It is even more crucial for facility staff to be able to recognize the signs and symptoms of trauma, emotional and behavioral effects of trauma, and to have an action plan of how to address their residents’ associated emotional and behavioral needs.  

F-tags that address trauma-informed care:

“Regulations state that the facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.” 

Relevant F-tags include, but are not limited to: 

  • F-659 qualified persons 
  • F-699 trauma informed care (effective 11/28/2019)
  • F-741 sufficient competent staff, behavioral health needs 
  • F-740 behavioral health services 
  • F-742 treatment/services for mental-psychosocial concerns
  • F-743 no pattern of behavioral difficulties unless unavoidable

F-tags effective 11/28/2019):

§ 483.25 Quality of Care. (m)Trauma-informed care. 
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

§ 483.40 (a) (1)

§483.40 (a) (1) Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment conducted pursuant to §483.70 (e). 

§ 483.40 (b)

  • §483.40 (b) Based on the comprehensive assessment of a resident, the facility must ensure that
  • §483.40 (b)(1) A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem, or to obtain the highest practicable mental and psychosocial well-being (as linked to history of trauma and/or post-traumatic stress disorder).

How can you identify a trauma history in your residents?

  • Review the resident’s admission records for the following:
    • Recent or past involvement in a traumatic event (e.g., MVA, falling, recent delirium) 
    • Mention of abuse or APS involvement in the records
    • Post-traumatic Stress Disorder (PTSD) listed as a diagnosis
    • Sexual assault history
    • Mention of combat experience in the military
  • Interview your residents.
  • When the facility social worker conducts an initial interview and completes the usual mood and mental status screens, they could ask whether the resident has a history of trauma.
  • Formal assessment measures can be utilized.
  • Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): 5-item screen that was designed for use in primary care settings. The measure begins with an item designed to assess whether the respondent has had any exposure to traumatic events.
  • Trauma Screening Questionnaire (TSQ): 10-item symptom screen that was designed for use with survivors of all types of traumatic stress. 

Action steps to prepare for trauma-informed care:

  • Be familiar with the Behavioral and Emotional Status Element Pathway that surveyors use to determine if your facility is providing necessary behavioral, mental, and/or emotional healthcare services to each resident.
  • Educate facility staff about trauma-informed care.
  • Conduct a facility self-assessment. 
  • Identify who will be the designated person(s) to assess for trauma history.
  • Identify which staff person(s) should be notified if a resident is exposed to a traumatic event during their stay.
  • Identify staff training needs and develop training surrounding trauma-informed care.
  • Implement trauma-informed practices and policies. 
  • Ensure you have a behavioral health provider with training and experience in recognizing and treating trauma who can provide consultation and psychological services for residents whom a trauma history has been identified.

Recognizing personal history variables is important in any interaction, but even more so in the LTC setting. Residents are in an environment where they often feel they don’t have much control over, are exposed to unpredictable noises, and are interacting with residents and staff who they some times may not know very well, all of which can increase anxiety. When a resident has a prior history of being exposed to life-threatening traumatic events, all of these variables can trigger and intensify their emotional and behavioral response. Therefore, it is important for facility staff to be able to:

  • Recognize trauma and its associated emotional sequelae.
  • Respond with empathy and respect.
  • Keep the resident’s personal trauma information private- provide the least amount of details that will still allow for personalization of care while avoiding re-victimization.
  • Create an emotionally and physically safe environment
  • Refer for behavioral health services in order to provide appropriate assessment and treatment by a competent professional.

Lisa Lind, Ph.D., is a psychologist with over 15 years of experience in both providing clinical services and publishing research in the area of trauma. She serves as the Chief of Quality Assurance for Deer Oaks- The Behavioral Health Solution. She also serves on the Board of Psychologists in Long-Term Care. 

References

Brewin, C. R., Rose, S., Andrews, B., Green, J., Tata, P., McEvedy, C., Turner, S., and Foa, E. B. (2002). Brief screening instrument for post-traumatic stress disorder. The British Journal of Psychiatry, 181, 158-162.
CMS (2017). State operations manual. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
Department of Health and Human Services. (2017). Behavioral and Emotional Status Critical Element Pathway. http://cmscompliancegroup.com/wp-content/uploads/2017/08/CMS-20067-Behavioral-Emotional.pdf
Prins, A., Bovin, M. J., Kimerling, R., Kaloupek, D. G., Marx, B. P., Pless Kaiser, A., & Schnurr, P. P. (2015). The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5).
Quality Improvement Organizations (2018). Resources to Support Trauma Informed Care for Persons in Post-Acute and Long-Term Care Settings. https://www.hsag.com/contentassets/1f0061b9de2f40f696242d5a0c6c68e8/trauma_informed_care_resources_fnl_508.pdf
Simon, A. & Loush, M. (2017) Trauma informed care: Implications for the future. https://www.michigan.gov/documents/lara/4._Trauma_Informed_Care_Presenation_554764_7.pdf