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Based on record review and interview the hospital failed to ensure staff followed discharge policy to include providing patients with medication instructions, a prescription and follow-up appointment times for 1 (P[patient] 1) out of 4 (P1-P4) patients reviewed for discharge education. These failures could likely result in a patient not getting antipsychotic medications as ordered upon discharge, and result in a relapse of psychiatric symptoms by disrupting the brain chemicals; withdrawal symptoms including inability to sleep, anxiety, agitation, restlessness, flu-like symptoms, or mood swings; a rare but potentially life-threatening condition called Neuroleptic malignant syndrome (NMS) characterized by fever muscle rigidity (muscles that don't bend), confusion, and fast heartbeat.

The findings are:

A. Record review of the facility's policy titled "Discharge Planning" dated April 2025, revealed follow-up appointments and referrals should be part of the discharge process. Discharge documents should be reviewed with patients and family/guardian including education on medication.

B. Record Review of P1's medical record for admission date 01/31/25 through 02/11/25 revealed the following:

1) Order dated 02/04/25 for Olanzapine (antipsychotic) 5 milligrams twice a day, this order was stamped discontinued on 02/07/25.

2) Order dated 02/07/25 for Olanzipine 7.5 milligrams twice a day, this order was stamped discontinued on 02/10/25.

3) Order dated 02/10/25 for Olanzipine 7.5 milligrams twice a day stated "continue on discharge".

C. Record review of discharge paperwork provided to P1 on discharge date 02/11/2025 revealed:

1) Bubble pack (pop out pill dispensing package) with prescription dated 02/03/25 for Olanzipine 5 milligrams twice a day was given to patient on discharge.

2) Bubble pack with prescription dated 02/10/25 for Olanzipine 7.5 milligrams twice a day was also given to patient on discharge.

3) There was no evidence that a prescription or further medication or additional medication instructions were provided to P1 at discharge on 02/11/2025.

D. Record review of P1's chart form titled, "Aftercare Plan/Discharge Instruction Form" dated 02/03/2025 at 2:03 PM listed appointment date for follow-up appointments with no time listed. This form was given to P1 on discharge.

E. During an interview with S (Staff) 3, nonclinical on 06/24/2025 at 10:00 AM, S3 explained that the hospital had an in-house pharmacy that utilized bubble packs to provide medications to patients while they were admitted to the hospital. These bubble packs should not be given to patients at discharge. S3 added in the event the in-house pharmacy did not have a particular medication in stock the hospital would order from a pharmacy delivery service.

F. During an interview with S6, clinical on 06/24/2025 at 11:45 AM, S6 reported that every patient has a prescription called to the pharmacy for 30 days of medication prior to discharge , S6 also explained that bubble packs used in-house are not given to the patient at discharge.

G. During an interview with complainant on 06/24/2025 at 3:45 PM, it was expressed P1 was sent home with 2 bubble packs. The complainant stated there was no explanation of how to take the medications and no prescription was provided. A list of follow-up appointments was given with no time, they called the number to confirm appointments and was told no appointments had been scheduled. The hospital provided the patient and family with only enough antipsychotic medication to last one week.

H. During an interview with S2, clinical on 06/24/25 at 4:20 PM, S2 was unable to confirm a prescription had been sent to the pharmacy for P1 while reviewing P1's medical records for admission dated 1/31/2025. S2 was unable to locate documentation showing where patient or family had been asked what pharmacy they preferred to use. S2 stated the documentation in P1's medical records for admission dated 1/31/2025 - 02/11/2025 declared P1 had been provided with "21 pills in partially used bubble packs" upon discharge 02/11/2025.

Based on record review and interview the hospital failed to provide discharge planing to include post hospital care, for example, medication prescription and after care provider appointments for 1 (P [patient] 1) out of 4 (P1-P4) patients reviewed for discharge education. This failure could likely result in a patient not getting medications as ordered upon discharge, and not getting provider follow-up appointments.

The findings are:

A. Refer to Tag A-0398.