Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) received trauma-informed care to identify and mitigate potential triggers. Resident 62, who was cognitively intact and had a history of trauma from being a war veteran and a motor vehicle accident, was not assessed for specific triggers that could re-traumatize him. Despite having a care plan indicating a potential for mood problems related to PTSD, there was no documented evidence of a trauma history assessment for this resident. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Plan Of Correction
An assessment has been conducted for resident R62 with triggers identified. A house wide audit has been done for all residents with a Post Traumatic Stress Disorder diagnosis. All identified residents will have an assessment completed to identify triggers and interventions. Nursing and social services will be educated on a newly created Trauma Informed care policy. The Nursing Home Administrator or designee will audit new resident diagnoses and new admissions for diagnoses of post-traumatic stress for 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.