Failure to Develop PTSD Care Plan for Resident with Behavioral Health Diagnoses
Penalty
Summary
The facility failed to develop a care plan addressing Post-Traumatic Stress Disorder (PTSD) for a resident who was admitted following a serious motor vehicle accident resulting in multiple fractures and the death of a family member. Although the resident was prescribed medications such as Prazosin for PTSD-related nightmares and Temazepam for insomnia, and behavioral health notes documented diagnoses including adjustment disorder with anxiety, major depressive disorder, generalized anxiety disorder, and insomnia, there was no corresponding care plan for PTSD or mood/behavior issues. The resident's Minimum Data Set (MDS) and Preadmission Screening and Resident Review (PASARR) did not reflect a mental illness diagnosis, and a follow-up PASARR was not completed despite new diagnoses being documented in behavioral health notes. Interviews with facility staff revealed gaps in communication and responsibility regarding care plan updates and PASARR processes. The Social Service Director was unaware of the PTSD diagnosis and acknowledged that a care plan should have been created, while the MDS coordinator admitted to missing the Prazosin order and not routinely reviewing behavioral health provider notes. The facility's PASARR policy did not include procedures for updating the PASARR when new mental illness diagnoses were identified, contributing to the oversight in care planning for the resident's PTSD and related behavioral health needs.