Failure to Include PTSD in Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan that addressed all of a resident's identified needs, specifically omitting the diagnosis of post-traumatic stress disorder (PTSD) for one resident. Record review showed that the resident had a diagnosis of PTSD, moderate cognitive impairment, and required assistance with personal care. Despite this, the care plan initiated for the resident did not include PTSD as a problem or risk, nor did it outline measurable objectives or interventions related to this diagnosis. Interviews with staff revealed a lack of awareness regarding the resident's PTSD diagnosis and uncertainty about whether it should be included in the care plan. The facility's policy requires that care plans be comprehensive and include measurable objectives to address all medical, nursing, mental, and psychosocial needs identified in the assessment. However, both the MDS coordinator and the DON indicated they were unaware of the need to care plan for PTSD, and the care plan did not reflect this diagnosis. This omission resulted in the failure to communicate the resident's PTSD needs to the care team, as required by facility policy.