Failure to Develop and Implement Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement a resident-specific plan of care for a resident diagnosed with post-traumatic stress disorder (PTSD), anxiety, and depression. Review of the resident's Minimum Data Set indicated intact cognition, and the resident's medical history included PTSD. However, there was no documented evidence in the physician's orders or psychiatric progress notes that the facility assessed the source of the resident's trauma, monitored for signs and symptoms of PTSD, identified triggers, or implemented interventions to avoid further trauma. The PASRR Level II Summary recommended a crisis/safety intervention plan, but this was not reflected in the resident's care plan. Interviews with the Clinical Care Coordinator/LPN and the Director of Nursing confirmed that the resident's clinical record and care plan did not address the PTSD diagnosis, including the necessary assessments and interventions. The lack of documentation and individualized planning for the resident's behavioral and emotional needs constituted a failure to provide trauma-informed and culturally competent care as required.