Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident identified as a trauma survivor, specifically a resident with Post Traumatic Stress Disorder (PTSD) resulting from the loss of a leg. The facility's policy mandates the development and implementation of a comprehensive care plan for each resident, which should include measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. However, the care plan for this resident did not identify the resident's PTSD triggers or strategies to avoid them, despite the resident's admission to the facility and a physician's order to consult psychiatry. Interviews with the resident and facility staff revealed that the resident expressed fear of hospitals and doctors, and felt more traumatized while at the facility. The facility lacked a social worker, and there was no evidence that the resident was evaluated by psychiatry or had a psychology visit. The Director of Nursing confirmed the failure to identify the resident's PTSD triggers and acknowledged that the psychology provider, who was supposed to evaluate the resident, did not do so as scheduled. This oversight contributed to the facility's failure to mitigate potential re-traumatization for the resident.
Plan Of Correction
1. Resident R278 no longer resides at the facility. 2. The records of other residents were audited for diagnoses of PTSD. 3. Care plans were reviewed and updated to include the history of what causes the PTSD, monitoring for specific signs and symptoms that triggers PTSD, and plan for appropriate interventions to mitigate the onset. 4. DON/designee to educate licensed staff on appropriate PTSD identification, triggers for awareness/prevention, and care planning PTSD. 5. DON/designee to audit new admissions 3x/week for 3 weeks and 2x/week for 2 weeks to monitor PTSD diagnosis, triggers, care plans. 6. Results to be submitted to QAPI for review and approval.