Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive care plan for trauma informed care for one resident with a history of trauma, specifically for a resident diagnosed with PTSD, major depressive disorder, conversion disorder, and anxiety. The resident was cognitively intact and had an active diagnosis of PTSD, as indicated by the most recent MDS assessment. Record review showed that there was no care plan addressing PTSD, no identification of individualized triggers, and no completed trauma assessment in the resident's medical record. Interviews with nursing staff and the DON confirmed that the social worker, who is responsible for trauma assessments and PTSD care plans, had not been available for several weeks, resulting in the absence of the required care plan and assessment.