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F0699
E

Failure to Provide Trauma-Informed Care for PTSD Residents

Beaver, Pennsylvania Survey Completed on 02-14-2025

Penalty

Fine: $28,71056 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide trauma-informed care to residents who are trauma survivors, as required by regulations. Specifically, the facility did not conduct Trauma Informed Care Evaluations for residents with PTSD, nor did it develop individualized care plans that addressed past trauma and identified triggers that could cause re-traumatization. This deficiency was identified for five residents, each with a diagnosis of PTSD, among other medical conditions. The facility's policy on trauma-informed care, dated 10/1/24, mandates the development of individualized care plans in collaboration with residents and their families to address past trauma and decrease exposure to triggers. Resident records revealed that assessments and care plans lacked the necessary components to address PTSD. For instance, Resident R33, admitted with major depressive disorder, opioid dependence, and PTSD, did not have a Trauma Informed Care Evaluation or a care plan with goals or interventions for PTSD. Similarly, Residents R51, R141, R168, and R296 also lacked appropriate assessments and care plans for PTSD. Interviews with facility staff confirmed these deficiencies, indicating a systemic failure to implement trauma-informed care practices for residents with PTSD.

Plan Of Correction

1. R296 is no longer in facility. Care plans for R51, R33, R141, and R168 were updated to reflect triggers that may exacerbate PTSD symptoms. 2. A house audit will be completed to ensure all residents with a PTSD diagnosis have potential triggers identified in their plan of care. 3. Director of nursing or designee will in-service social workers on identifying triggers associated with a PTSD diagnosis so that the plan of care includes interventions to mitigate stressors. 4. Director of nursing or designee will audit 2 residents with a PTSD diagnosis weekly for 4 weeks to ensure care plan includes identified triggers and interventions to mitigate stressors. Audit findings will be shared with QAPI committee.

See complete original report
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