Failure to Address PTSD Triggers in Resident Care Plan
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD), major depressive disorder, and a traumatic subdural hemorrhage. Review of the resident's clinical record and care plan revealed that, although there was a care plan in place for a history of traumatic event, it did not address possible triggers that could cause re-traumatization for the resident. The quarterly Minimum Data Set (MDS) assessment confirmed the PTSD diagnosis, but the care plan lacked specific interventions or considerations for the resident's past experiences and preferences related to trauma. During an interview, the Social Service Director confirmed that the care plan for PTSD did not include identification or management of potential triggers for re-traumatization. This omission was found for one of four residents sampled for PTSD care, out of 33 residents reviewed. The deficiency was cited under 28 Pa. Code 211.12(c)(d)(3)(5) for nursing services, as the facility did not meet professional standards of practice in providing trauma-informed, culturally competent care.