Failure to Develop Person-Centered Care Plan for PTSD Diagnosis
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), despite the resident having a documented history of PTSD, delusional disorders, mood disorder, and major depressive disorder. A trauma-informed assessment was completed, and the resident was found to be cognitively intact with no behaviors noted during the assessment period. However, review of the care plan revealed there was no plan of care addressing the resident's PTSD diagnosis. Staff interviews confirmed that while the resident had some behaviors such as refusal of care and paranoid behavior, these were care planned separately and not specifically linked to PTSD. Nursing staff, including the MDS Nurse and the Director of Nursing, acknowledged that a person-centered care plan should have been developed for the resident's PTSD, including identification of triggers such as loud noises. The MDS Nurse stated that a care plan was not created because the resident had not exhibited any PTSD-related problems since admission. Despite this, the expectation was that staff should be aware of appropriate interventions should a PTSD episode occur. The lack of a specific care plan for PTSD constituted the deficiency identified during the survey.