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Based on clinical record review, review of policy and procedures and interview, it was determined the Facility failed to adhere to their policy for discharge planning for 8 (#1, #5, #6-#11) of 11 (#1-#11) clinical records. Failure to adhere to the Facility policy for discharge planning did not assure individual patient needs for discharge would be identified and coordinated with Community resources. The failed practice affected patients #1, #5, #6-#11 and would likely affect all patients admitted to the Facility. The findings were:

A. Clinical record review on 06/16 - 06/17/15 revealed:
1) Patient #1 was admitted on 06/10/15 and discharged on 06/15/15. The clinical record did not have evidence of an assessment of the patient's needs post discharge. The lack of discharge planning was confirmed by the Chief Nursing Officer (CNO) on 06/16/15 at 1620.

2) Patient #5 was admitted on 03/19/15 and discharged on 03/22/15. The clinical record did not have evidence of an assessment of the patient's needs post discharge. The lack of discharge planning was confirmed by Registered Nurse (RN) #2 on 06/16/15 at 1620.

3) Patient #6 was admitted on 03/23/15 and discharged on 03/27/15. The clinical record did not have evidence of an assessment of the patient's needs post discharge. The lack of discharge planning was confirmed by RN #2 on 06/17/15 at 0930.

4) Patient #7 was admitted on 03/29/15 and discharged 04/02/15. The clinical record did not have evidence of an assessment of the patient's needs post discharge. The lack of discharge planning was confirmed by RN #2 on 06/17/15 at 0945.

5) Patient #8 was admitted on 04/03/15 and discharged on 04/08/15. The clinical record did not have evidence of an assessment of the patient's needs post discharge. The lack of a discharge plan was confirmed by RN #2 on 06/17/15 at 0950.

6) Patient #9 was admitted on 04/09/15 and discharged on 04/13/15. The clinical record did not have evidence of an assessment of the patient's needs post discharge. The lack of a discharge plan was confirmed by RN #2 on 06/17/15 at 1000.

7) Patient #10 was admitted on 04/17/15 and discharged on 04/20/15. The clinical record did not have evidence of an assessment of the patient's needs post discharge . The lack of a discharge plan was confirmed by RN #2 on 06/17/15 at 1010.

8) Patient #11 was admitted on 03/01/15 and discharged on 03/05/15. The clinical record did not have evidence of an assessment of the patient's needs post discharge. The lack of a discharge plan was confirmed by RN #2 on 06/16/15 at 1330.

B. Review of the Facility policy "Discharge Planning" provided on 06/17/15 by the CNO revealed: "Policy: All patients have the right to receive a written discharge plan. Discharge Planning is a dynamic process initiated at admission, aimed at definition of post-hospital needs and planning for the recuperative period. The (hospital named) Discharge Planning Program is designed to assess individual patient needs and coordinate appropriate community resources. Procedures: Patients needing Discharge Planning are identified by the Discharge Planning Coordinator through a high-risk screening process utilizing the following criteria: The Discharge Planning Coordinator identifies patients' needs by: Reviewing the medical record, communicating with members of the interdisciplinary team, interviewing the patient and or family, questionnaires, guidelines for high-risk screening.

Based on clinical record review and interview, it was determined the Facility failed to include planning for discharge in the patient's nursing care plan for 8 (#1, #5, #6-#11) of 11 (#1-#11) clinical records reviewed. Failure to assess and plan the discharge needs of each patient did not assure individual patient needs for discharge would be identified and coordinated with Community resources at discharge. The failed practice affected patients #1, #5, #6-#11 and would likely affect all patients admitted to the Facility. The findings were:

A. Clinical record review on 06/16 - 06/17/15 revealed:
1) Patient #1 was admitted on 06/10/15 and discharged on 06/15/15. The clinical record did not have evidence of an assessment or care plan of the patient's needs post discharge. The lack of discharge planning was confirmed by the Chief Nursing Officer (CNO) on 06/16/15 at 1620.

2) Patient #5 was admitted on 03/19/15 and discharged on 03/22/15. The clinical record did not have evidence of an assessment or care plan of the patient's needs post discharge. The lack of discharge planning was confirmed by Registered Nurse (RN) #2 on 06/16/15 at 1620.

3) Patient #6 was admitted on 03/23/15 and discharged on 03/27/15. The clinical record did not have evidence of an assessment or care plan of the patient's needs post discharge. The lack of discharge planning was confirmed by RN #2 on 06/17/15 at 0930.

4) Patient #7 was admitted on 03/29/15 and discharged 04/02/15. The clinical record did not have evidence of an assessment or care plan of the patient's needs post discharge. The lack of discharge planning was confirmed by RN #2 on 06/17/15 at 0945.

5) Patient #8 was admitted on 04/03/15 and discharged on 04/08/15. The clinical record did not have evidence of an assessment or care plan of the patient's needs post discharge. The lack of a discharge plan was confirmed by RN #2 on 06/17/15 at 0950.

6) Patient #9 was admitted on 04/09/15 and discharged on 04/13/15. The clinical record did not have evidence of an assessment or care plan of the patient's needs post discharge. The lack of a discharge plan was confirmed by RN #2 on 06/17/15 at 1000.

7) Patient #10 was admitted on 04/17/15 and discharged on 04/20/15. The clinical record did not have evidence of an assessment or care plan of the patient's needs post discharge . The lack of a discharge plan was confirmed by RN #2 on 06/17/15 at 1010.

8) Patient #11 was admitted on 03/01/15 and discharged on 03/05/15. The clinical record did not have evidence of an assessment or care plan of the patient's needs post discharge. The lack of a discharge plan was confirmed by RN #2 on 06/16/15 at 1330.

B. Review of the facility policy "Discharge Planning" provided on 06/17/15 by the CNO revealed: "Policy: All patients have the right to receive a written discharge plan. Discharge Planning is a dynamic process initiated at admission, aimed at definition of post-hospital needs and planning for the recuperative period. The (hospital named) Discharge Planning Program is designed to assess individual patient needs and coordinate appropriate community resources. Procedures: Patients needing Discharge Planning are identified by the Discharge Planning Coordinator through a high-risk screening process utilizing the following criteria: The Discharge Planning Coordinator identifies patients' needs by: Reviewing the medical record, communicating with members of the interdisciplinary team, interviewing the patient and or family, questionnaires and guidelines for high-risk screening.