Failure to Assess and Address PTSD Needs for Residents
Penalty
Summary
The facility failed to ensure that staff were competent and adequately prepared to meet the behavioral health needs of residents diagnosed with Post-Traumatic Stress Disorder (PTSD). Specifically, two residents with PTSD were not properly assessed for their condition or for potential triggers upon admission. The Social Services Director (SSD) did not complete or document PTSD assessments for these residents, and there was no evidence of monitoring or interventions tailored to their behavioral health needs. The Director of Nursing (DON) confirmed that documentation regarding PTSD and triggers was missing and acknowledged that such assessments should have been completed at admission. Staff members, including Certified Nurse Assistants (CNAs) and Licensed Vocational Nurses (LVNs), were unaware of the residents' PTSD diagnoses and did not know what triggers to monitor for or how to provide appropriate care. Interviews with the residents revealed that they had not been approached about their PTSD or triggers, and one resident expressed discomfort and anxiety due to staff not being informed about his specific triggers, such as loud noises and large groups. The lack of staff awareness and training resulted in the absence of individualized interventions to address the residents' mental health needs. A review of facility policies and job descriptions indicated that the Social Services Director was responsible for completing comprehensive assessments and care plans, including identifying and addressing mental and psychosocial needs. However, these responsibilities were not fulfilled, as evidenced by the lack of PTSD assessments and individualized care planning for the affected residents. The facility's policy also required nursing staff to identify and document mental health conditions and behaviors, which was not done in these cases.