Failure to Develop Baseline Care Plan for Resident with PTSD and Antipsychotic Use
Penalty
Summary
Staff failed to develop a baseline or comprehensive care plan within 48 hours of admission for a resident with multiple diagnoses, including PTSD, anxiety, depression, and a recent fracture. The facility's policy requires that a baseline care plan be created within 48 hours to address immediate needs, including initial goals, physician's orders, dietary needs, therapy, social services, and PASARR recommendations. However, review of the resident's records showed that no care plan was developed within the required timeframe to address the resident's PTSD diagnosis or the use of the antipsychotic medication Quetiapine (Seroquel). Interviews with facility staff confirmed awareness of the resident's PTSD diagnosis and antipsychotic medication order, but acknowledged that a care plan addressing these needs was not created as required. The social worker stated she was aware of the PTSD diagnosis but did not know the resident's trauma history or triggers and admitted that a care plan should have been developed but was not. The unit manager also confirmed that no baseline or comprehensive care plan was found in the resident's record to address the use of antipsychotic medication.