Failure to Provide PTSD Training to Nursing Staff
Penalty
Summary
The facility failed to provide in-service training on Post-Traumatic Stress Disorder (PTSD) for all 106 nursing staff members, which was necessary to adequately care for a resident with a PTSD diagnosis. The resident, who had a history of sickle-cell disease, bipolar disorder, and PTSD, reported that staff did not understand her condition or know how to respond to her triggers. She described experiencing 'fight or flight' reactions when approached in certain ways and felt that her behaviors were misunderstood by staff as being difficult rather than as symptoms of her PTSD. Interviews with multiple staff members, including CNAs and an LVN, revealed a lack of knowledge about PTSD and an absence of any in-service training on the topic. Staff were generally unaware of the presence of residents with PTSD in the facility and could not describe appropriate interventions or responses for individuals with this diagnosis. The Director of Staff Development and the Director of Nursing both acknowledged the importance of PTSD awareness and training but confirmed that no such 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 and skills. However, the lack of PTSD-specific training meant that staff were not equipped to identify or address the unique needs of residents with PTSD, as required by the facility's own policies and federal regulations.
Plan Of Correction
F726: Competent Nursing Staff CORRECTIVE ACTION Resident 47 is no longer a resident of the facility as of 3/26/25. Resident discharged safely and expressed gratitude for the help of staff members. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/25/25 and 3/28/25, MDS personnel audited residents with diagnosis of PTSD and 2 residents were identified. IDT met with the residents and both have no verbalization of any new onset of acute distress or poor handling/interaction/care by staff. MEASURES AND SYSTEMIC CHANGES On 3/28/25, DSD conducted an in-service to Staff regarding care of patients with PTSD. DSD to ensure competency skills check on care for patients with PTSD are done upon hire and annually thereafter. Licensed nurses will discuss triggers and preferences of residents with PTSD during the shift huddle. 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. 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.