Failure to Implement Specific PTSD Interventions for Resident
Penalty
Summary
The facility failed to implement specific interventions for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's medical record documented diagnoses including PTSD, insomnia, delusional disorder, dementia with behavioral disturbance, and general anxiety. The Trauma Informed Care Assessment indicated that the resident had experienced traumatic events and suffered from nightmares related to those events. However, the care plan only noted the presence of nightmares and did not address the actual trauma or identify possible triggers for the resident's PTSD. Interviews with facility staff, including the Minimum Data Set Coordinator and the Director of Nursing, revealed that neither staff nor the resident's family knew the specific trauma or triggers associated with the resident's PTSD. The current care plan lacked specific goals and interventions to address the resident's PTSD triggers, despite the facility's policy requiring trauma-informed care that minimizes triggers and re-traumatization.