Failure to Address PTSD and Trauma Triggers in Care Plan
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care in accordance with professional standards of practice for a resident with a diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with a history of traumatic subarachnoid hemorrhage, traumatic brain injury, and PTSD. Upon review, it was found that the resident's care plan, initiated after admission, did not address the resident's history of traumatic events or identify possible triggers that could cause re-traumatization. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan did not include interventions or considerations for the resident's PTSD and potential triggers.
Plan Of Correction
1. Resident R7 care plan was immediately updated to include PTSD. 2. Residents with a d/x of PTSD care plan will be reviewed/updated to include possible triggers. 3. Care plans for residents with a d/x of PTSD will be audited/implemented and interviewed for triggers. New admissions will be audited for PTSD d/x and triggers, 2x week for 2 weeks and then 1x week for 3 weeks. 4. Audits will be submitted to the QAPI committee for review.