Failure to Develop Baseline Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a baseline care plan addressing the immediate needs of a resident with a diagnosis of post-traumatic stress disorder (PTSD) within 48 hours of admission. Documentation from the resident's previous facility and the FL2 form both indicated a diagnosis of PTSD, and physician orders included medication for this condition. However, the baseline care plan completed by the MDS Nurse did not include any goals or interventions related to PTSD or associated behaviors. Interviews with staff revealed that the omission was due to either lack of awareness of the diagnosis or waiting for additional information regarding trauma history and triggers from the discharging facility. Staff interviews further indicated that the expectation was for PTSD and related behaviors to be included in the baseline care plan, but this was not done. The DON was not aware of the resident's PTSD diagnosis at the time of admission and expected to be notified of such diagnoses and related information. The MDS Nurses acknowledged that PTSD and its associated behaviors should have been addressed in the baseline care plan, but this was not completed due to incomplete information at the time of admission.