Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Fine: $17,3458 days payment denial
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 address the specific needs of a resident with an active diagnosis of Post-Traumatic Stress Disorder (PTSD). During a clinical record review, it was found that the resident's care plan, last updated on 2/19/25, did not include a trauma-informed approach or identify potential triggers related to the resident's PTSD. The quarterly Minimum Data Set (MDS) confirmed the active diagnosis of PTSD, but there was no evidence in the care plan that trauma-informed care or trigger identification had been incorporated. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a trauma-informed care plan for the resident.