Failure to Develop and Implement Care Plans for PTSD and Diabetes Management
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents with specific clinical needs. For one resident with severe cognitive impairment and a diagnosis of Post Traumatic Stress Disorder (PTSD), there was no care plan in place to address PTSD, despite documentation of the diagnosis in the resident's assessment. Interviews with staff revealed a lack of awareness and understanding of the resident's PTSD, its triggers, and appropriate interventions. The resident's Power of Attorney identified specific triggers such as loud noises and fireworks, but this information was not incorporated into a care plan, and staff were either unaware of the PTSD diagnosis or unclear about how to address it. In a separate case, another resident with a diagnosis of diabetes and an active order for insulin did not have a care plan addressing diabetes management or insulin administration. The interdisciplinary team reviewed care plans but failed to develop one for the resident's diabetes or insulin use. The MDS Coordinator confirmed the absence of an active care plan for these needs. These omissions were identified through record review and staff interviews during the survey process.