Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a comprehensive assessment and individualized care plan were completed for a resident diagnosed with post-traumatic stress disorder (PTSD). According to the facility's own Trauma Informed Care policy, care and services should be tailored to address the needs of trauma survivors, including identifying triggers and updating care plans with interventions based on input from the resident, family, and mental health professionals. However, review of the clinical record for a resident with diagnoses of major depressive disorder, vascular dementia, and PTSD revealed that the care plan did not specifically address the resident's PTSD diagnosis or include interventions tailored to this condition. Further review showed that the care plan only identified a general risk for mood changes related to depression, anxiety, and PTSD, without any interventions specific to PTSD. Staff interviews confirmed that the care plan lacked a specific focus on PTSD and that the resident had not been given a trauma assessment to determine their needs. The facility's process of referring residents with a PTSD diagnosis for psychiatric consultation and trauma assessment was not followed in this case, resulting in the omission of necessary care planning for the resident's PTSD.