Failure to Develop PTSD Care Plan for Resident
Penalty
Summary
The facility failed to initiate a care plan addressing Post-Traumatic Stress Disorder (PTSD) for a resident who had documented diagnoses of PTSD in two separate OBRA evaluations completed in 2024 and 2025. The resident was admitted with multiple diagnoses, including cerebral infarction, heart failure, and major depressive disorder, and was noted to be cognitively impaired and dependent on assistance for bathing and dressing. Despite these findings and the documented PTSD diagnosis, the resident's care plan did not include interventions or goals related to PTSD. Both the social worker and the DON acknowledged the omission when questioned, and the facility's policy requires that changes in a resident's mental or psychosocial functioning be incorporated into the care plan.