Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and develop a care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). Despite the resident's medical record and psychiatric progress notes indicating a diagnosis of chronic and controlled PTSD, the initial and subsequent social service histories did not document PTSD, and the resident was not assessed for trauma-related needs. The quarterly MDS assessment did indicate PTSD as a current diagnosis, along with other psychiatric and medical conditions, but this information was not incorporated into the resident's care planning. There was no care plan in place to address the resident's PTSD triggers or to provide trauma-informed care as required by facility policy. The policy mandates screening for trauma history upon admission, obtaining physician orders for mental health evaluation if trauma is identified, and developing individualized care plans to mitigate triggers. An interview with the Regional Registered Nurse confirmed that the resident was not assessed for PTSD and that a comprehensive plan of care was not developed to address this diagnosis.