Failure to Provide Trauma-Informed Care for PTSD Residents
Penalty
Summary
The facility failed to provide trauma-informed care for residents diagnosed with PTSD, as evidenced by the lack of identification and management of specific triggers that could lead to re-traumatization. Three residents, identified as R23, R45, and R85, were affected by this deficiency. Resident R23, admitted with diagnoses including anxiety, cerebellar ataxia, and PTSD, had a care plan that did not specify triggers related to their PTSD. Similarly, Resident R45, with a history of cerebral palsy, high blood pressure, quadriplegia, and PTSD, had a care plan that failed to identify specific triggers related to their relational trauma from maternal abuse. Resident R85, diagnosed with atrial fibrillation, bipolar disorder, anxiety, and PTSD, also had a care plan lacking in specific trigger identification related to their history of physical abuse and a vehicular accident. The Social Services Director confirmed the facility's failure to identify specific triggers and ensure trauma-informed care for these residents. This deficiency was noted during a review of clinical records and staff interviews, highlighting the facility's non-compliance with the requirement to provide culturally competent, trauma-informed care to mitigate potential re-traumatization.
Plan Of Correction
1. Residents R23, R85, and R45 care plan was updated for PTSD including interventions. Residents R23, R85, and R45 has not experienced any negative effects. 2. Initial audit of PTSD care plans were performed. 3. Social Workers will be educated on the need to care plan residents with PTSD and suicidal ideation interventions. 4. Audits of residents who trigger for PTSD are care planned and person centered 3x a week times 2 weeks, 2x a week times 2 weeks, and 1x week times 2 weeks. 5. The monthly reviews will be submitted to the QAPI committee for review and approval.