Failure to Develop and Implement PTSD Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing post-traumatic stress disorder (PTSD) triggers and interventions for a resident with a documented diagnosis of PTSD. The resident, who had intact cognition and required assistance with all activities of daily living, had a history of complex trauma and abuse, as well as other significant medical conditions including alcoholic cirrhosis, renal failure, hepatic encephalopathy, and fibromyalgia. Clinical notes from a psychology provider indicated the resident experienced re-experiencing of trauma, mistrust of authority, and anxiety about dependency on others, and recommended specific memory care approaches and coping tools. Despite this, the resident's care plan did not include PTSD triggers or interventions. Interviews with facility staff, including nursing assistants, registered nurses, the clinical coordinator, social worker, and assistant director of nursing, revealed that none were aware of the resident's PTSD history or specific triggers. Staff confirmed that trauma assessments and related care planning were not completed or included for this resident, despite facility policy requiring trauma-informed care assessments and individualized care plans for residents with a history of trauma or PTSD. The absence of this information in the care plan meant staff were not equipped with the necessary knowledge or strategies to appropriately respond to the resident's needs related to PTSD.