Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
A deficiency was identified when the facility failed to provide trauma-informed care for a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD). The resident reported that his PTSD was triggered by loud noises and other people screaming during the night, which caused him to wake up panicked. Despite this information, the facility did not identify or document these specific triggers in the resident's care plan. Additionally, there was no evidence in the clinical record that the facility collaborated with the resident, his family, friends, or relevant healthcare professionals such as psychologists or mental health professionals to develop and implement individualized interventions. The lack of identification of triggers and absence of a collaborative, individualized care approach resulted in the facility not meeting the requirements for culturally competent, trauma-informed care for this resident.
Plan Of Correction
Staff completed a review of resident #59's medical record to identify triggers related to the resident's diagnosis of PTSD (Post Traumatic Stress Disorder). An updated care plan was completed by social services to provide individualized care. A review of current residents with the diagnosis of PTSD has been completed. Any findings were addressed with a revised care plan to include potential triggers relating to the resident's diagnosis that may retraumatize the resident. Education was provided by the director of nursing or designee to the clinical and nursing management staff on the basis of identifying potential triggers for residents with the diagnosis of PTSD and the proper annotation within the care plans. Audits will be completed on 5 charts weekly for one month and biweekly for 3 months relating to the residents with diagnosis of PTSD and ensure the care plan has been appropriately annotated. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.