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Based on interview and record review, the facility staff failed to contact Patient A's outpatient pharmacy for medications ordered for the patient by the physician at discharge.

As a result, Patient A did not receive her medications in a timely basis as prescribed by the physician.

According to the admission record, Patient A, an adolescent was admitted to the facility on an involuntary basis on 8/13/18, from a General Acute Care Hospital Emergency Room, due to suicidal ideation.

Patient A was subsequently discharged to the care of her mother on 8/16/18.

Per review of the physician's discharge orders, dated 8/16/18, the physician ordered, "Please provide 2 weeks supply of medication".

On 9/4/18 at 10:15, the Director of Nursing stated the discharging nurse was responsible for calling the discharge medications to the patients' Health Maintenance Organization's pharmacy.

On 9/4/18 at 10:30, RN 1 stated patients are discharged upon the written order of a physician. In addition a form entitled, Transition Record Aftercare-Discharge Instructions is completed by the discharging nurse. RN 1 stated he as charge nurse would delegate the responsibility of calling in the requisition to the discharging RN who in turn would call in the prescription to Patient A's Health Maintenance Organization's pharmacy. RN 1 stated he could not recall if he delegated the discharge instructions to the discharging nurse on 8/16/18.

On the Transition Record After-Care Discharge Instructions, in the section entitled Patient/Family Instructions, and to be completed by the RN (Registered Nurse), a box is to be checked regarding medications. This section was left blank by the RN, indicating it was not done.