Nursing homes and other healthcare facilities must ensure that residents who do not have a diagnosis of a mental or psychosocial adjustment difficulty or a documented history of trauma and/or post-traumatic stress disorder (PTSD) upon admission, do not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors while residing in the facility. To do this, they must monitor the resident closely, assess and plan care for any concerns identified, accurately document changes, share concerns with the interdisciplinary team, ensure appropriate follow-up assessment, provide staff with training opportunities, monitor and provide ongoing assessment, review and revise care planned interventions and accurately document the reason for revision in the resident's medical record. If a resident does develop such a pattern, the facility must evaluate whether the distress is attributable to their clinical condition and demonstrate that the change in behavior was unavoidable. Additionally, they must ensure an accurate diagnosis of a mental disorder or psychosocial adjustment difficulty, or PTSD is made by a qualified professional and provide services with an individualized care approach that support the needs of residents with these indicators.

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