Failure to Care Plan for PTSD Diagnosis
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was admitted with multiple diagnoses, including emphysema, anxiety, and PTSD. Observation, interview, and record review revealed that the resident's care plan did not document the PTSD diagnosis or include related goals and interventions. The Director of Nursing confirmed that the PTSD diagnosis should have been included in the care plan but was not.