Failure to Provide Resident-Centered Behavioral Health Services for PTSD
Penalty
Summary
The facility failed to provide resident-centered behavioral health services to a resident with a documented history of post-traumatic stress disorder (PTSD) and major depressive disorder. The resident was admitted with these diagnoses, and assessments, including the Trauma Informed Care Screener and the Minimum Data Set, confirmed both the presence of trauma and intact cognitive skills. Despite the resident's disclosure of PTSD to staff and documentation in the care plan and psychiatric notes indicating ongoing PTSD-related anxiety, the facility did not implement specific behavioral health interventions beyond psychiatric visits. Interviews with facility staff, including the LVN, DON, and ADON, revealed that no additional behavioral health services or interventions were provided to address the resident's PTSD. Staff acknowledged awareness of the resident's condition but confirmed that no assessments or services were in place to identify triggers or prevent behavioral responses related to PTSD. The facility's own policy required person-centered behavioral health care, but this was not followed for the resident in question.