Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). Upon review of the clinical records, it was found that the resident's care plan did not identify PTSD symptoms or triggers, nor did it include specific interventions to minimize these triggers and prevent re-traumatization. This oversight was noted during a review conducted on December 11, 2024. Interviews with facility staff revealed a lack of awareness and action regarding the resident's PTSD diagnosis. The Director of Social Services confirmed that she was unaware of the diagnosis and that no care plan had been established to address it. Additionally, the Nursing Home Administrator acknowledged the facility's inability to provide culturally competent, trauma-informed care in line with professional standards, which would account for the resident's experiences and preferences to mitigate potential triggers.
Plan Of Correction
PTSD care plan has been added to resident 78 plan of care. To identify residents with the potential to be affected, the Social Service Director/designee will audit residents with current PTSD diagnosis to ensure care plan is in place. To prevent re-occurrence, the NHA/designee will educate the Social Service Director to ensure the plan of care for residents with PTSD has care plan updated with specific needs. To monitor and maintain compliance, the Social Service Director/designee will audit new admissions with a diagnosis of PTSD weekly for 4 weeks, then monthly for 2 months to ensure the care plan is present and specific needs are identified. All results will be brought to the QAPI committee.