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Based on record review and interview, the hospital failed to ensure implementation of an appropriate discharge plan for each patient. This deficient practice was evidenced by failing to ensure discharge medications were sent home with the patient at time of discharge for 1 (#1) of 3 sampled patients.
Findings:

Review of hospital Discharge Planning Policy, Policy Number: DC-1-001, Effective Date: May 2024 revealed, in part: Purpose: To assure that the discharge planning process and the discharge plan are consistent with the patient's goals for care and his or her treatment preferences, and to ensure an effective transition of the patient from the hospital to post-discharge care, as well as reduce factors leading to preventable hospital readmissions or post discharge complications.

Review of Patient #1's medical record revealed, in part, diagnoses and medical history of stage IV sacral decubitus, type II diabetes mellitus, hypertension, bipolar disorder, morbid obesity, and intellectual disability.

Review of Patient #1's medical record revealed discharge date 08/21/2024. Patient #1 had to be transported by ambulance and discharge disposition was home.

Review of Patient #1's discharge instructions dated 08/21/2024 revealed, in part, to pick up 19 medications prior to discharge home.

In an interview on 09/17/2024 at 1:31 p.m., S2Chief Clinical Officer indicated when a patient discharged from the hospital the discharging nurse should send the patient's medications, if available, with the patient at time of discharge.

Review of Patient #1's Discharge Planning Addendum dated 08/21/2024, 9:37 a.m. revealed: Social Worker spoke with patient's mother for follow up. She stated that Patient #1's medications were not sent home with her. Social Worker immediately contacted administration and medications were couriered to patient's home and the mother signed for them at 2:49 p.m.

In an interview on 09/23/2024 at 10:46 a.m., S1Administrator stated Patient #1's medications were at the patient's bedside at time of discharge. S1Administrator confirmed Patient #1's discharge medications were not sent home with the patient at time of discharge.