Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to two residents, both of whom have been diagnosed with Post Traumatic Stress Disorder (PTSD). Resident R36 was admitted to the facility and had a Minimum Data Set (MDS) assessment indicating PTSD, among other diagnoses. However, a review of Resident R36's care plan revealed that it did not include any goals or interventions related to managing PTSD. This was confirmed by the Registered Nurse Assessment Coordinator, who acknowledged the absence of a care plan addressing PTSD for this resident. Similarly, Resident R85, who also has PTSD along with anxiety and depression, did not have a care plan that included goals or interventions for PTSD. During an interview, Resident R85 mentioned that no one from the facility had inquired about her trauma or potential triggers. The Social Services Director confirmed that the facility failed to provide trauma-informed care to mitigate triggers that could cause re-traumatization for both residents.
Plan Of Correction
R36 and R85 care plans were immediately updated to include PTSD. Like residents were audited to ensure no other care plans needed modifications for PTSD. Request submitted to PCC on 1/8/2025 to add PTSD form. Education on PTSD will be provided to the social workers and RNAC by the NHA or designee on or before 2/11/2025. Audits will be conducted on PTSD on care plans by DON or designee weekly x 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.