Inadequate PTSD Care Planning for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents diagnosed with post-traumatic stress disorder (PTSD). The facility's policy on trauma-informed care mandates that residents who are trauma survivors receive culturally competent care, including the development of individualized care plans that address their specific needs and triggers. However, upon review, it was found that the care plans for both residents lacked specific goals, implementations, or outcomes directly related to their PTSD diagnosis. For Resident R139, the care plan mentioned PTSD in relation to other health concerns but did not include any specific interventions or goals for managing PTSD. Similarly, Resident R157's care plan did not document any treatment or services related to their PTSD diagnosis. The deficiency was confirmed through interviews with facility staff, including the Director of Nursing, who acknowledged that the care plans were incomplete regarding the specific needs of residents with PTSD. The facility's failure to adhere to its own policy and federal regulations resulted in inadequate care planning for residents with PTSD, potentially impacting their mental and psychosocial well-being. The report highlights the need for the facility to ensure that all residents with mental health conditions receive appropriate and individualized care planning to address their specific needs.
Plan Of Correction
Resident R139 R157 PTSD trauma informed comprehensive care plans updated to include person centered interventions. Step 2 All residents with PTSD diagnosis was designated a comprehensive person-centered care plan. Step 3 Social Services department educated on comprehensive person-centered care-plan related to PTSD. Step 4 Managers/ designee will conduct audits weekly x4, monthly x 2 to per facility protocol. Findings will be reviewed during QAPI meeting.