Failure to Develop and Implement Comprehensive Care Plan for PTSD Following PASRR Level 2 Determination
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with newly diagnosed post-traumatic stress disorder (PTSD) following a recent psychiatric hospitalization. The resident, who had a history of neurological and psychiatric conditions including hemiplegia, seizure disorder, anxiety, and bipolar disorder, experienced an acute exacerbation of mental health symptoms, including severe depression and suicidal ideation. After expressing suicidal thoughts and being placed on a legal hold, the resident was hospitalized and subsequently diagnosed with PTSD. Upon the resident's return to the facility, documentation showed that the baseline care plan referenced the need to implement PASRR recommendations for mental health needs. However, there was no evidence in the medical record that a comprehensive care plan specifically addressing PTSD was developed or implemented. Additionally, the facility did not conduct or document a PASRR Level 2 evaluation after the resident's acute change in condition, despite the previous PASRR Level 1 screening being outdated and no longer reflective of the resident's current mental health status. Further review revealed that a PASRR Level 2 determination had been completed by the hospital and indicated the need for specialized services, but this information was not incorporated into the resident's medical record or the most recent MDS assessment. The MDS Coordinator was unaware of the PASRR Level 2 process and confirmed that the new diagnoses and recommendations were not included in the care planning process, resulting in the absence of a comprehensive plan to address the resident's updated mental health needs.