Failure to Address PTSD Triggers and Reasons in Care Plan
Penalty
Summary
The facility failed to adequately address the reason and trigger areas for a resident's diagnosis of post-traumatic stress disorder (PTSD) as part of the care planning process. Clinical record review showed that the resident had diagnoses including Parkinsonism, depression, and PTSD, with a care plan that only included general interventions such as reporting traumatic reactions to the provider or charge nurse. The care plan did not specify the resident's PTSD triggers or the underlying reason for the diagnosis, despite the resident being cognitively intact and on medication for PTSD. Interviews with facility staff, including the RN, MDS Coordinator, ADON, and DON, revealed a lack of knowledge regarding the resident's PTSD triggers and the specific reason for the diagnosis. Staff were unable to provide details about the resident's traumatic reactions or triggers, and the care plan was not individualized to address these aspects. Additionally, the facility did not have a policy related to care plans and relied on CMS regulations for guidance.