Failure to Assess and Care Plan for PTSD Triggers
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to identify and assess a resident's history of Post-Traumatic Stress Disorder (PTSD) to determine specific triggers that could lead to re-traumatization. Record review showed that the resident, admitted in 2018 and diagnosed with PTSD, did not have an assessment or care plan documentation addressing potential trauma triggers or interventions to prevent re-traumatization. The care plan and assessments lacked evidence of any evaluation or planning related to the resident's trauma history and associated needs.