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Based on a review of documentation and staff interview, it was determined that the facility failed to ensure discharge planning included instructions regarding the patient's monthly injection and planning follow-up appointments to ensure that the patient received the monthly injection on the due date. There was also no evidence that the contact with the patient's physician included communication of treatment recommendations for the patient.

Findings were:

Facility Policy entitled "Determining Discharge Criteria and Medicare Discharge Appeal Rights", states in part "#3. Discharge criteria are determined through Nursing Assessments, Therapist Psychosocial Assessments, and the provider CPE. These criteria will be discussed and agreed upon with the patient during treatment team meetings, and changes to expected length of stay or discharge criteria will be documented on the treatment planning update and signed by the patient and the treatment team. As the patient reaches their goals and objectives and is deemed safe for discharge, the provider will order the discharge."

Facility Policy entitled "Patient's Bill of Rights" states in part "#26. You have the right to a treatment plan for your stay in the hospital that is just for you. You have the right to take part in developing that plan, as well as the treatment plan for your care after your leave the hospital. This right extends to your parent or conservator if you are a minor, or your legal guardian when applicable. You have the right to request that your parent/conservator or legal guardian take part in the development of the treatment plan. You have the right to request that any other person of your choosing, e.g., spouse, friend, relative, etc., take part in the development of the treatment plan. You have a right to expect that your request be reasonably considered and that you will be informed of the reasons for any denial of such a request. Staff must document in your medical record that the parent/guardian, conservator, or other person of your choice was contacted to participate."

Review of the patient's medical record revealed no documented evidence that the discharge planners' (staff #7) contact with the patient's physician included communication of treatment recommendations regarding Invega Sustenna 156 mg intramuscular due November 7, 2017. The patient's follow-up appointment with his physician was scheduled for November 13, 2017, five (5) day after the due date of the patient's psychoactive monthly injection.
The above findings were confirmed by the Director of Nursing and the Discharge Planner the afternoon of 02/20/2018.