Failure to Develop Individualized PTSD Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). Despite the resident's medical record indicating diagnoses of generalized anxiety, borderline personality disorder, major depressive disorder, and PTSD, there was no assessment completed to identify the specific cause of PTSD or potential triggers that could lead to re-traumatization. The care plan only generally referenced psychiatric and mood status but did not specify PTSD triggers or interventions to minimize risk. Interviews revealed that the resident was cognitively intact and independently mobile, and had reported being bothered when people entered her personal space, which was a known trigger for her PTSD. Staff interviews indicated a lack of awareness regarding the resident's PTSD triggers, with both nursing and CNA staff stating they were unaware that proximity could cause the resident anxiety until the resident herself informed them. The Social Services Director confirmed that while a PTSD checklist was completed and triggers were discussed verbally, this information was not documented in the medical record or care plan. As a result, no formal interventions were developed or communicated to staff to address the resident's PTSD triggers, and the facility did not have a PTSD-specific policy in place.