Failure to Implement Comprehensive Care Plan for PTSD
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). The facility's policy on Trauma-Informed Care (TIC) aims to provide care that is safe, respectful, and responsive to trauma, preventing re-traumatization and promoting healing. However, upon reviewing the clinical records and facility policy, it was found that the facility did not create a care plan addressing the resident's PTSD, including their trauma-related needs, preferences, and triggers. The resident, who had a history of depression, anxiety, and PTSD, was on Seroquel for trauma-related issues. During an interview, the resident reported an incident where being stuck in an elevator triggered their PTSD, causing past traumatic memories to resurface. Despite this, there was no evidence in the clinical record of a care plan that addressed the resident's specific needs related to PTSD, as recommended by the psychiatric evaluation and therapy notes.
Plan Of Correction
1. Resident R220's care plan has been updated. 2. 5 residents' care plans will be audited to ensure proper comprehensive plan. 3. Staff will be educated on the components of this regulation with an emphasis on developing and implementing comprehensive care plans. 4. 5 care plans will be audited to ensure proper comprehensive care plan 1x week for 1 month, 2x a month for one month, and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.