Failure to Develop Comprehensive PTSD Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the diagnosis of Post-Traumatic Stress Disorder (PTSD) for a resident who was admitted with PTSD, anxiety, unspecified psychosis, and depression. The resident had severe cognitive impairment, as indicated by a BIMS score of 00, and exhibited verbal and physical behavioral symptoms directed at others one to three days per week. Despite these documented behaviors and the resident's history of PTSD, the care plan did not include any section to identify triggers or interventions specific to PTSD. The resident's wife, who is also the Power of Attorney, reported that she was not consulted to help develop a care plan for PTSD, even though she was aware of specific triggers such as loud noises, violence on television, and being handled. The Director of Nursing confirmed that a comprehensive care plan for PTSD was absent from the resident's medical record.