Failure to Develop PTSD-Specific Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed a resident's history of post-traumatic stress disorder (PTSD). The resident was admitted with diagnoses including major depressive disorder and had a positive trauma screen, with documentation indicating a history of trauma related to an attempted assault in her 20s. The resident's Minimum Data Set showed intact cognitive skills and a need for assistance with daily activities. Despite these findings and a psychiatric note confirming ongoing PTSD-related anxiety, the care plan did not specifically address PTSD. During interviews and record reviews, it was confirmed that staff were aware of the resident's PTSD, but no care plan interventions specific to PTSD were in place. The Assistant Director of Nursing acknowledged that a care plan for PTSD should have been developed, including interventions such as referral to a female psychologist. The facility's policy requires comprehensive care plans with measurable objectives and timeframes for all identified needs, but this was not followed for the resident's PTSD.