Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify specific triggers related to post-traumatic stress disorder (PTSD) and develop an individualized plan of care to prevent re-traumatization for Resident #11. The resident, who has a history of unspecified dementia, major depressive disorder, generalized anxiety, and PTSD, was observed reading a book and did not respond to an interview attempt. Her care plan mentioned the risk of re-traumatization related to childhood trauma but lacked specific interventions tailored to her needs. Interviews with staff revealed a lack of awareness and training regarding PTSD triggers and individualized care approaches. A Certified Nursing Assistant (CNA) was unaware of Resident #11's PTSD diagnosis and could not identify her triggers. The Director of Nursing (DON) acknowledged that staff are educated to look for behaviors but did not know the resident's specific triggers. The Social Services Director (SSD) confirmed that the care plan should include interventions related to approach and preferences for care but had not individualized triggers for PTSD care plans. The facility's policy on Trauma Informed Care emphasized the importance of culturally sensitive and person-centered care, yet staff interviews indicated a gap in training and implementation. The SSD was aware of the resident's trauma history but had not seen psych notes related to physical and sexual abuse. The deficiency highlights a failure to provide trauma-informed care by not adequately identifying and addressing the resident's PTSD triggers in her care plan.
Plan Of Correction
1. The care plan for resident #11 was updated to include specific triggers related to prevent re- to by the MDS director on. 2. MDS director or designee will complete quality assurance checks on resident care plans to ensure they have an individualized plan to prevent re- by. 3. Reeducation was provided to the IDT team that resident care plans must be individualized and include specific triggers related to, to prevent re- by NHA or designee on. 4. Quality assurance checks will be conducted of four random residents care plans by the MDS director or designee 3 times a week for 6 weeks then weekly for an additional 6 weeks to ensure they are individualized with specific triggers related to to prevent re- to. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.