Failure to Develop Person-Centered Care Plan for PTSD
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). Record review showed that the resident, who had multiple diagnoses including Parkinson's disease, breast cancer, edema, transient ischemic attack, dementia, PTSD, major depressive disorder, and atrial fibrillation, required maximal assistance with all activities of daily living and was cognitively intact according to a recent assessment. Despite the identification of PTSD in the resident's assessment, the current care plan did not include person-specific, measurable goals or interventions for PTSD. This omission was confirmed during an interview with the DON, who acknowledged that a care plan addressing PTSD should have been in place for the resident.