Failure to Develop Personalized PTSD Care Plan
Penalty
Summary
The facility failed to develop a personalized care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), major depressive disorder, opioid abuse, and alcoholic cirrhosis. Despite the facility's policy requiring trauma-informed care that accounts for residents' experiences and preferences, the care plans reviewed did not document the resident's specific traumatic experiences or include interventions to mitigate identified triggers. The resident's trauma history, as documented in a brief trauma questionnaire, included personal experiences of serious accidents, exposure to toxic substances, physical assault, and other very stressful events. Care plans initiated for the resident referenced PTSD and related risks but did not detail the traumatic events or provide individualized interventions to address or reduce exposure to triggers that could cause re-traumatization. During an interview, the Social Worker confirmed that the PTSD care plan was not personalized and lacked documentation of the resident's traumatic experiences and specific strategies to mitigate triggers, as required by facility policy.