Failure to Update Care Plan After New PTSD Diagnosis
Penalty
Summary
The facility failed to update the care plan for one resident after a new mental health diagnosis was identified. Clinical record review showed that the resident had a diagnosis of Post Traumatic Stress Disorder (PTSD) and anxiety, as documented in the Minimum Data Set (MDS) assessment and the Pre-admission Screening & Resident Review (PASRR). The electronic health record listed PTSD as a diagnosis, but the care plan, last revised on 6/20/25, did not reflect this updated diagnosis or address PTSD as required. The Trauma Informed Intake assessment indicated that the trauma care plan should be reviewed or updated, but this was not done. During staff interviews, the MDS Coordinator stated that the resident did not know her PTSD triggers and that there was no facility policy guiding what to include in the care plan, though she followed the Resident Assessment Instrument (RAI). The DON stated that she expected PTSD to be addressed in the care plan. Facility policy required care plans to be reviewed and revised after significant changes in a resident's condition, but this was not followed in this case.