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Based on review of medical records, facility policy and procedure, and staff interviews, it was determined that the facility failed to document implementation of the discharge plan for 1 (#2) of 5 patients whose medical records were reviewed.

A review of facility Behavioral Health policy #: CC.020, Title "Discharge", last reviewed/revised 01/20/12, revealed that the patient treatment team was responsible for developing a safe discharge plan. The registered nurse (RN) was responsible for completing the discharge instructions. Discharge medications were to be listed on the instruction sheet. The RN was responsible for reviewing all discharge instruction including medications with the patient. The patient was to be given the opportunity to ask questions for clarification of instructions. After review and explanation the patient would sign the discharge instructions indicating receipt and understanding of the instructions. The RN was also responsible for writing a discharge note on the patient's medical record. The documentation was to include time of discharge, who accompanied the patient, the patient's mood and behavior at discharge (including specification that the patient does not verbalize or demonstrate current danger to self or others), and that medication and belongings were returned to the patient.

Review of the physician's discharge summary for patient #2 revealed that the patient was discharged home from the facility on 05/03/2012.

Patient #2's medical record lacked documented evidence of a discharge nursing assessment, assessment of the patient's mood and behavior at discharge, medication review, discharge instructions, time of discharge from the nursing unit or mode of discharge transportation.

An interview was conducted with the facility's Director of Behavioral Health 06/13/2012, at 2:30 p.m. in the Medical Records Department. The interviewee confirmed that the required nursing documentation related to patient #2's discharge was not in the patient's record.

An interview was conducted on 06/13/2012, at 2:10 p.m. with the RN (personnel file #1), responsible for patient #2's care at the time of discharge from the facility's Behavioral Health Unit. The interviewee stated that he/she remembered the patient, but could not recall discharging the patient from the facility. The nurse was unable to provide an explanation for the missing documentation or provide additional information related to discharge of the patient.