Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The clinical record review revealed that the resident was admitted on March 1, 2023, with a diagnosis of PTSD. The care plan for the resident included goals and interventions to improve mood and manage PTSD symptoms, such as administering medications, monitoring for side effects, and providing behavioral health consults as needed. However, the facility did not identify specific triggers related to the resident's PTSD that could lead to re-traumatization. An interview with the Nursing Home Administrator revealed that the facility did not inquire about the resident's PTSD triggers from his wife until after the surveyor's inquiry. The administrator confirmed that the resident's wife was unaware of specific triggers but mentioned that the resident would wake up and move to another room when experiencing PTSD-related issues. This lack of proactive identification and management of PTSD triggers in the care plan led to the deficiency, as the facility did not adequately address the potential for re-traumatization of the resident.
Plan Of Correction
F0699 1. Resident 57 and his wife reported no triggers to his PTSD and would not discuss further. 2. Audit of current residents with diagnoses of PTSD will be audited to ensure they have specific triggers in their PTSD care plans. 3. Education will be completed with social services on identifying and care planning specific triggers for a resident with the diagnosis of PTSD. 4. Random audits will be completed weekly by the Social Services Director or designee for 4 weeks then monthly for 2 months to ensure residents with a diagnosis of PTSD have specific triggers in their PTSD care plans. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.