Failure to Address PTSD in Resident's Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan that addressed the mental and psychological needs of a resident with a diagnosis of post-traumatic stress disorder (PTSD). Record reviews showed that the resident was admitted with diagnoses including unspecified dementia, anxiety disorder, and PTSD, and had a moderately impaired cognitive status as indicated by a BIMS score of 10/15. Despite documentation in progress notes of the resident being confrontational and experiencing war-related hallucinations, the admission assessment on the Minimum Data Set (MDS) did not include PTSD as a diagnosis in Section I. The lead MDS Coordinator confirmed that PTSD should have been included in the assessment. Further review of the resident's care plan revealed no evidence that the PTSD diagnosis was addressed. Interviews with facility staff, including the social worker, confirmed that the comprehensive care plan did not include interventions for PTSD. Facility policies required that all identified problems, including those found in the MDS and other assessments, be addressed in the care plan with specific goals and interventions. The failure to include PTSD in both the MDS and the care plan resulted in the resident's mental health needs not being fully addressed as required by facility policy and regulatory standards.