Failure to Develop and Implement Comprehensive Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a history of service-related PTSD, as required by policy. Although the resident's care plan noted a preference for individual activities and included pharmacological interventions for depression and anxiety, it did not document the resident's PTSD diagnosis, potential triggers, or specific interventions to address these needs. The resident's trauma questionnaire was incomplete and did not address emotional responses or physical injuries related to traumatic events. The diagnosis of PTSD was not included in the resident's MDS or the facility's matrix provided to surveyors. Interviews with staff revealed a lack of awareness regarding the resident's PTSD diagnosis and associated triggers. The Activities Team Leader was unaware of the PTSD diagnosis and did not participate in interdisciplinary meetings, relying solely on the care plan for information. The MDS Nurse acknowledged the omission of PTSD from the MDS assessment, and the DON was unaware of the diagnosis and its absence from the care plan. As a result, staff were not informed of the resident's specific needs related to PTSD, and the care plan was not updated to reflect all identified needs from the comprehensive assessment.