Failure to Assess and Care Plan for Resident with PTSD
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to assess a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for past traumas and to identify known triggers, as required by facility policy. Record review showed that the resident had a documented history of physical and sexual abuse and neglect, as noted in a psychiatry note. Although the care plan referenced mood alterations and PTSD, it only included general observations for changes in psychosocial or mood state and did not document an assessment of past traumas, identification of potential triggers, or the development of a trauma-specific care plan. An administrative nurse confirmed that staff did not complete a trauma assessment, identify triggers, or create a trauma care plan for the resident.