Failure to Communicate PTSD Diagnosis to Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff were informed of a resident's diagnosis of post-traumatic stress disorder (PTSD), resulting in a lack of appropriate treatment and services for the resident. The resident, who is a veteran, was admitted with a documented diagnosis of PTSD, as noted in psychological progress notes by a nurse practitioner. These notes indicated that the resident experienced PTSD symptoms, including nightmares several times per month, but was not seeking treatment for them. The PTSD diagnosis was listed under 'Other Diagnoses' in the progress notes. Despite this documentation, the registered nurse responsible for assessing residents and developing care plans was unaware of the PTSD diagnosis, as the psychological notes were not communicated to him. Additionally, both the Director of Nursing and the Administrator confirmed they were not aware of the resident's PTSD diagnosis or symptoms. It was acknowledged that there was no established communication system for the psychologist to report new diagnoses to facility staff, resulting in the failure to provide trauma-informed care as outlined in the facility's policy.