Failure to Provide Trauma-Informed, Individualized Care Planning for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and implement individualized, trauma-informed care plan interventions for a resident with a diagnosis of post-traumatic stress disorder (PTSD), among other mental health conditions. The resident's Minimum Data Set (MDS) assessment indicated intact cognition and the ability to communicate needs. The care plan identified potential for altered mood related to PTSD, major depressive disorder, generalized anxiety disorder, suicidal ideation, and personality disorder, but interventions were generic and did not address specific trauma triggers or utilize a trauma-informed approach. The care plan lacked identification of triggers to avoid potential re-traumatization and did not include individualized strategies based on the resident's trauma history. Interviews with the resident revealed that she is sensitive to loud noises due to past trauma and prefers staff to knock softly, but facility staff had not inquired about her trauma history or specific triggers. Several staff members, including the infection preventionist and a nursing assistant, were unaware of the resident's PTSD diagnosis or related triggers. The assistant director of nursing, director of nursing, and regional consulting registered nurse confirmed the resident's PTSD diagnosis and acknowledged the absence of a PTSD-specific care plan with related interventions. The facility's policy requires individualized trauma-based care plans to address past trauma, but this was not implemented for the resident in question.