Failure to Address Resident's PTSD and Mental Health Needs
Penalty
Summary
The facility failed to provide medically-related social services to assist a resident in attaining or maintaining their mental and psychosocial health. Upon admission, the resident had diagnoses of Post Traumatic Stress Disorder (PTSD), Anxiety, and Major Depressive Disorder, which were documented in both the medical record and the Pre-admission Screening and Resident Review Assessment. A Social Service Assessment was completed, including a trauma screen, but the resident responded negatively to all trauma-related questions. The assessment did not include input from the resident's representative, nor did it probe for PTSD triggers or address the resident's PTSD diagnosis. The care plan noted a communication problem but did not include goals or interventions for depression or PTSD. There was no referral for psychological evaluation or behavioral services, and the Director of Social Services' notes did not address PTSD. Interviews with the DON and Director of Social Services confirmed that there was no referral for psychological services and that PTSD was not addressed in the care plan or assessments, with the Director of Social Services stating she did not feel further action was necessary due to the negative trauma screen responses.