Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
Mid Valley Health Care Center failed to develop and implement an individualized, person-centered plan of care to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The deficiency was identified during a revisit survey conducted on January 2, 2025, which revealed that the facility did not address the resident's PTSD diagnosis in their care plan. Specifically, the care plan lacked documentation of symptoms or identified triggers related to PTSD and did not include resident-specific interventions aimed at minimizing triggers and preventing re-traumatization. An interview with the Director of Social Services confirmed that the facility did not provide culturally competent, trauma-informed care in accordance with professional standards of practice. The facility failed to consider the resident's experiences and preferences to mitigate triggers and promote emotional safety, as required by 42 CFR Part 483 Subpart B and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
Plan Of Correction
Step 1 Resident #2 was reevaluated by in-house Psych provider to accurately assess appropriateness of PTSD Diagnosis. In-house Psych Provider has provided a more appropriate diagnosis for Resident, plan of care has been updated to include same. Step 2 To identify others with the likelihood to be affected, all Residents identified with a current PTSD diagnosis were evaluated for appropriateness of diagnosis by in-house Psych provider. The DON/designee will audit care plans to ensure that the cause of trauma and triggers are identified with personalized interventions implemented to manage same or have diagnosis removed and plan of care updated if PTSD diagnosis was found to be inaccurate. Step 3 To prevent a future reoccurrence, DON/designee will educate the Interdisciplinary Team that Residents identified to have a PTSD diagnosis will have their plan of care updated with the cause of trauma and potential triggers, with personalized interventions implemented. To prevent a future reoccurrence, the DON/designee will educate the Interdisciplinary Team that if a PTSD diagnosis is identified with no known trauma or triggers identified, the in-house Psych Provider will be consulted to evaluate the appropriateness of the diagnosis, providing documentation to support or refute PTSD diagnosis. Step 4 To monitor and maintain ongoing compliance the Social Worker/designee will audit all new admissions or any Resident obtaining a new diagnosis of PTSD to ensure accuracy of the diagnosis and their plan of care contains the identified trauma and potential triggers with personalized interventions implemented to manage PTSD weekly x 4 and then monthly x 2. Results of audits will be forwarded to Facility QAPI committee for further review and provide any necessary recommendations as needed.