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Based on record reviews and interviews, the hospital failed to provide documented evidence in the medical record (1) to indicate discharge planning included the method Patient #1 was to utilize to obtain a medication (Invega Sustenna) that was ordered to be continued after discharge from the hospital, and (2) the patient and the patient's family member were counseled, and received and understood the discharge instructions to prepare them for post-hospital care. This deficient practice was identified for 1 (#1) of 5 (#1-#5) records reviewed for discharge planning. Findings:

Review of the policy entitled "Discharge Planning" (NO: CTS-097) presented as the current policy, revealed in part: "Procedure: 3. RN/Therapist/Discharge Planner: Documents final discharge plans on Discharge Instruction Form. Including: Appointments set up. Medications to be taken post-discharge. Community resources to be utilized after discharge. Discharge instructions are provided to the patient in a manner that is understandable. 4. Therapist/Utilization Review/RN: When patients are transferred or discharged, necessary information is exchanged/ communicated to other service providers with patient consent. Minimal information includes: ... Relevant biopsychosocial status at transfer or discharge. Community Resources or referrals provided to the client.

Review of a policy entitled "Discharge Process" (NO: CTS-087) presented as the current policy, revealed in part: "Procedure: 1.2. Nursing staff will assist the patient in: 1.2.3. Understanding discharge procedures; 1.2.5. Understanding discharge instructions. 1.3. Nursing staff will document the discharge on the nursing progress notes. This documentation will include: 1.3.4. The current medications of the patient at discharge. 1.3.5. The patient's method for obtaining medication (if applicable). 1.3.6. The informing of patients and patient's awareness of any follow-up appointments."

Patient #1

A review of the medical record revealed Patient #1 was an 18-year-old male who was admitted to the hospital on 11/04/15 and discharged on 11/11/15. Diagnoses included Intermittent Explosive Disorder; Major Depressive Disorder, Recurrent Severe Without Psychotic Features; a history of Asperger's and ADHD. Patient #1 was initially sent to the hospital on an involuntary basis, but signed a formal voluntary admission form on 11/05/15 at 1:30 a.m.

1) to indicate discharge planning included the method Patient #1 was to utilize to obtain a medication (Invega Sustenna) that was ordered to be continued after discharge from the hospital

A review of the medical record revealed a referral/prescription form completed by S4APRN on 11/10/15 for the medication, Invega Sustenna, to be administered intramuscularly on an outpatient basis with the first dose due date identified as 11/17/15, and then to be administered every 4 weeks. Further review of the medical record revealed there was no documentation in the medical record indicating this referral/prescription to Company A had been forwarded on 11/11/15.

In an interview on 12/16/15 at 2:25 p.m., S1ADM indicated Patient #1's referral/prescription to Company A was faxed in conjunction with another patient's information and forms. S1ADM reviewed Patient #1's medical record, and she confirmed there was no documentation in the medical record to indicate the patient's referral/prescription for Invega Sustenna was forwarded to Company A.

2) the patient and the patient's family member were counseled, received, and understood the discharge instructions to prepare them for post-hospital care.

Review of Patient #1's medical record revealed the discharge orders were written on 11/11/15.

Review of the Discharge Instruction sheet revealed the patient and/or a family member had not signed the discharge instruction sheet. Further review of the Discharge Instruction sheet revealed there was no documentation on the Discharge Instruction sheet as to how and where Patient #1 would receive the injection of Invega Sustenna.

In an interview on 11/16/15 at 1:00 p.m., S3RN indicated her usual role in the hospital unit is to perform the admissions and discharges for patients. S3RN reviewed the Discharge Instruction sheet and stated she documented most of the information on the Discharge Instruction sheet, but at some point, she had to leave the unit, and S4RN completed the sheet which included the documentation, under Current Medications, "Invega Sustenna, 156 milligrams, intramuscularly in one week, 11/15/15 due." S3RN indicated she met with Patient #1 on the day of discharge and reviewed the information and instructions on the Discharge Instruction sheet which included the information about the Invega Sustenna injections. S3RN indicated she signed the form at the Nurse Signature section. S3RN confirmed she did not obtain a signature from Patient #1 on the Discharge Instruction sheet after reviewing the instructions with him, and S3RN confirmed the Discharge Instruction sheet was not signed by Patient #1 or any family member. S3RN also confirmed there was no documentation that she spoke to Patient #1 or Patient #1's family member about the procedure for receiving the Invega Sustenna injections.

In an interview on 12/16/15 at 1:16 p.m., S4RN, indicated both Patient #1's mother and father came to pick up the patient at discharge. S4RN also indicated she met with Patient #1, his mother, and his father at the time Patient #1 was discharged and explained all of the information on the Discharge Instruction sheet to Patient #1's mother which included all of Patient #1's medications and an explanation of the role of Company A, and that Company A was to contact the patient and the family with instructions for Patient #1 to receive his next dose of Invega Sustenna. S4RN further indicated the contact information for Company A was provided to the patient and the patient's mother. S4RN reviewed the entire medical record for Patient #1, and confirmed there was no documentation in the medical record of this interaction with Patient #1 and his mother, and there should have been.

Based on record review and interview, the hospital failed to ensure a patient's treatment plan included an inventory of the patient's strengths and disabilities for 1 (#1) of 5 (#1-#5) records reviewed for treatment plans. Findings:

Review of a policy entitled Treatment Planning, NO: RC-017, presented as the current policy revealed the following, in part: "Policy: ...The treatment plan is patient-specific, individualized, and includes defined problems and needs, measurable goals and objectives based on assessed needs, strengths, and limits/weaknesses, frequency of care, treatment and services...."

Patient #1

A review of the medical record revealed Patient #1 was an 18-year-old male who was admitted to the hospital on 11/04/15 and discharged on 11/11/15. Diagnoses included Intermittent Explosive Disorder; Major Depressive Disorder, Recurrent Severe Without Psychotic Features; a history of Asperger's and ADHD. Patient #1 was initially sent to the hospital on an involuntary basis, but signed a formal voluntary admission form on 11/05/15 at 1:30 a.m.

A review of Patient #1's Treatment Plan revealed Patient #1's strengths and weaknesses were not identified on the treatment plan.

In an interview on 12/16/15 at 2:25 p.m., S1ADM confirmed that the treatment plan was not complete and was missing information identifying Patient #1's strengths and weaknesses, and the treatment plan should have included Patient #1's strengths and weaknesses.

Based on record review and interview, the hospital failed to ensure a patient's treatment plan included a substantiated diagnosis for 1 (#1) of 5 (#1-#5) records reviewed for treatment plans. Findings:

Patient #1

A review of the medical record revealed Patient #1 was an 18-year-old male who was admitted to the hospital on 11/04/15 and discharged on 11/11/15. Diagnoses included Intermittent Explosive Disorder; Major Depressive Disorder, Recurrent Severe Without Psychotic Features; a history of Asperger's and ADHD. Patient #1 was initially sent to the hospital on an involuntary basis, but signed a formal voluntary admission form on 11/05/15 at 1:30 a.m.

A review of Patient #1's Treatment Plan revealed the treatment plan did not include any documented psychiatric or medical diagnoses. The spaces where the diagnoses were to be documented were left blank.

In an interview on 12/16/15 at 2:25 p.m., S1ADM confirmed that the treatment plan was not complete and did not have any psychiatric or medical diagnoses documented on the treatment plan, and the psychiatric and medical diagnoses should have been documented on Patient #1's treatment plan.

Based on record review and interview, the hospital failed to ensure a patient's treatment plan included long term goals for 1 (#1) of 5 (#1-#5) records reviewed for treatment plans. Findings:

Review of a policy entitled Treatment Planning, NO: RC-017, presented as the current policy, revealed the following, in part: "Policy: ...The treatment plan is patient-specific, individualized, and includes defined problems and needs, measurable goals and objectives based on assessed needs, strengths, and limits/weaknesses, frequency of care, treatment and services...."

Patient #1

A review of the medical record revealed Patient #1 was an 18-year-old male who was admitted to the hospital on 11/04/15 and discharged on 11/11/15. Diagnoses included Intermittent Explosive Disorder; Major Depressive Disorder, Recurrent Severe Without Psychotic Features; a history of Asperger's and ADHD. Patient #1 was initially sent to the hospital on an involuntary basis, but signed a formal voluntary admission form on 11/05/15 at 1:30 a.m.

A review of Patient #1's Treatment Plan revealed, in part, the treatment plans for Mood Disorder-Depressed, Self-Harm, and Aggressive Behavior did not have any long-term goals documented on the treatment plans.

In an interview on 12/16/15 at 2:25 p.m., S1ADM confirmed that the treatment plan was not complete and did not contain long-term goals identified and documented, and the treatment plan should have had long-term goals documented.