Failure to Address PTSD and Develop Care Plan After Elevator Incident
Penalty
Summary
The facility failed to develop a plan of care for a resident diagnosed with PTSD, anxiety, and depression, following a distressing incident where the resident was trapped in an elevator. The resident, who had a history of PTSD, hypertension, depression, and a nonhealing diabetic foot ulcer, experienced a traumatic event when the elevator malfunctioned, causing severe anxiety and triggering PTSD symptoms. Despite the resident's request for psychological support, there was no documented evidence that the facility informed the physician or therapist about the incident or the resident's request for therapy. Interviews with staff confirmed the resident's distress and the lack of immediate psychological intervention. The Nursing Home Administrator was aware of issues with the elevator prior to the incident but did not take action to shut it down until after the resident was trapped. The facility's failure to address the resident's mental health needs and the lack of a care plan for the resident's PTSD and related conditions contributed to the deficiency.
Plan Of Correction
1. Resident R220 was seen by psychological services. 2. Residents with PTSD will be seen by psychological services to ensure proper plan is in place. 3. Staff will be educated on the components of this regulation with an emphasis on managing behavioral difficulties appropriately. 4. Audits of 5 residents with PTSD will ensure they have been seen by psychiatric services 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.