Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD), as required by federal regulations. The resident, who had a history of sickle-cell disease, bipolar disorder, and PTSD, reported that staff did not understand her PTSD diagnosis or how to respond to her triggers. She described experiencing automatic 'fight or flight' responses when staff approached her in certain ways, and felt that her reactions were misinterpreted as being difficult or acting out, rather than as symptoms of her condition. Interviews with staff members, including Certified Nursing Assistants (CNAs), a Licensed Vocational Nurse (LVN), the Director of Staff Development (DSD), and the Director of Nursing (DON), revealed a lack of awareness and training regarding PTSD. CNAs were either unfamiliar with PTSD or unaware of any residents with the diagnosis, and none recalled receiving in-service training on the topic. The LVN and DSD both acknowledged the importance of staff awareness of PTSD, but were unaware of any residents with the diagnosis and confirmed that no specific PTSD-related training had been provided to staff. A review of the facility's policy on behavioral assessment and intervention indicated that behavioral health services should be provided by qualified staff with the necessary competencies. However, the lack of staff knowledge and training regarding PTSD, as well as the absence of specific interventions for the resident's PTSD, demonstrated that the facility did not ensure trauma-informed care in accordance with professional standards and the resident's needs.
Plan Of Correction
CORRECTIVE ACTION On 3/25/25, an IDT care plan was conducted with the resident regarding Post Traumatic Stress Disorder to ensure that residents who are trauma survivors will receive competent trauma-informed care, and residents' experiences and preferences in order to eliminate or mitigate re-traumatization. On 3/28/25, DSD provided an in-service to staff regarding resident 47's specific PTSD triggers and preferences. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/7/2025, DON reviewed all residents to check for PTSD diagnosis and found 2 other residents with PTSD diagnosis. On 3/28/25, IDT met with both residents to discuss PTSD triggers and preferences. On 3/28/25, DON provided an in-service to staff regarding both residents' triggers for PTSD. MEASURES AND SYSTEMIC CHANGES DON/Designee will review all newly admitted residents with Post Traumatic Stress Disorder during the daily (Monday to Friday) clinical meeting to ensure that staff are aware of residents' experiences and preferences. Licensed nurses will discuss triggers and preferences of residents with PTSD during the shift huddle. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.