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Based on clinical record review, policy and procedure review and interview, the Facility failed to to determine how the patient's initial post-discharge needs for medication would be met for one (#20) of two (#19 and #20) patients that were readmitted after being discharged from the Facility. Failure to determine if Patient #20 had resources for obtaining prescribed medication, identified by Patient #20 as a trigger for readmission five days after discharge, was likely to impair Patient #20's safety and negatively impact their ability to sustain recovery. The findings were:

A. Review of Patient #20's clinical record on 08/18-08/19/2016 revealed the following:
1) Patient #20 was admitted to the Facility on 06/18/16 and discharged on 06/22/16. This admission occurred five days after previous discharge from the Facility on 06/13/16.

2) Patient #20 presented with complaints of "increased suicidal ideation, no current plan, since her discharge on 06/13/16 ...Patient stated she didn't fill her prescriptions and has had no meds."

3) Review of the Psychiatric Evaluation and History and Physical dated 06/19/16 at 1055 revealed the History of Present Illness on Admission: "The patient had been acutely hospitalized here at BridgeWay last month. The patient stated that upon getting discharged, she did not have any money to afford her medications. Patient started having an exacerbation of her depressive symptoms."

B. Review of Policy #PC-057 "Discharge or Transfer Criteria, Planning and Process" revealed "discharge Planning: the process that involves determining the appropriate post-hospital discharge destination for a patient; identifying what the patient requires for a smooth and safe transition from the hospital to his/her discharge destination; and beginning the process of meeting the patient's identified post-discharge needs. The goal of discharge planning is to move the patient back into the setting in which they were living prior to admission." "The discharge process includes but may not be limited to: ...referrals are made for medical issues, medication management, pain management, addictive services and community based support groups...". "A written aftercare plan is completed by the Social Service and Nursing staffs. A copy is given to the patient/family/guardian at the time of discharge or transfer. The Social Services staff will clearly indicate the information pertaining to outpatient appointments and community based services, other recommendations, diagnosis, and type of discharge."

C. The Clinical Director was interviewed on 08/19/16 at 1440 and stated the Social Worker assigned to the patient was at present the same person who performed the Discharge Planning. The Social Worker was to document the disposition and arrangements made for the patients at discharge. The process was that the Facility will provide transport for patients if needed, if medications are needed, the transport takes them by the Pharmacy then to the address the Facility provides. At the time of interview, the Clinical Director confirmed there was no documentation at the time of discharge by a Social Worker of resources or arrangements made for the post-discharge needs for Patient #20.