Failure to Identify PTSD Triggers and Provide Resident-Centered Interventions
Penalty
Summary
The facility failed to identify potential triggers for Post-Traumatic Stress Disorder (PTSD) and did not implement resident-centered interventions for a resident admitted with a diagnosis of PTSD. Upon admission, the resident's Brief Trauma Questionnaire did not address the PTSD diagnosis or identify possible behavioral triggers, and the care plan was not updated to include interventions or triggers related to PTSD. The resident had a complex medical history, including Parkinson's Disease, COPD, Lupus, Generalized Anxiety Disorder, Major Depression, and substance dependence. Despite these diagnoses, the facility did not adequately assess or plan for the resident's PTSD-related needs. Following a conversation with the Social Service Director about possible alternative placements, the resident became suspicious and believed she was being involuntarily discharged, which was not the case. The resident subsequently experienced severe emotional distress, including a manic episode and PTSD symptoms, and was unable to be redirected or emotionally regulated by staff interventions. The situation escalated to the point where the resident attempted to leave the facility, resulting in police and emergency medical services involvement and eventual transfer to a hospital for evaluation and treatment. The lack of trauma-informed and culturally competent care contributed to the exacerbation of the resident's behavioral symptoms.