Woodard Creek Health: Missing Discharge Records - WA

Staff at Woodard Creek Health & Rehabilitation failed to complete discharge documentation for residents moving to other facilities and didn't provide required bed-hold notices when residents left on therapeutic leaves, according to a September inspection report.

The violations left residents without proper documentation of their care needs and unaware of their rights to hold their beds during temporary absences.

Resident 2 arrived at the facility in June with dementia and difficulty swallowing. Care plans indicated the person would stay short-term before returning home, but progress notes from July 1 show the resident instead transferred to another long-term care facility.

The facility sent medications and belongings with the departing resident but failed to complete a discharge summary. The discharge instructions form remained blank.

Staff B, a registered nurse and director of nursing, told inspectors on September 4 that the facility sent receiving facilities "orders, progress note, medication/treatment administration and provider notes" for Resident 2. But Staff B acknowledged they "didn't always complete the discharge summary or instructions."

"They should have been doing it," Staff B said.

Facility policy requires nursing or social services staff to prepare discharge summaries and post-discharge plans before any resident transfer. The policy, dated October 2021, specifically states these documents must be completed for each resident prior to transfer or discharge.

A second resident faced different documentation failures during therapeutic leaves from the facility.

Resident 3, who had congestive heart failure and liver cirrhosis, lived at Woodard Creek long-term and was cognitively intact and independent with daily activities. Progress notes show the resident left on a leave of absence May 2, but the medical record contained no documentation that staff offered a bed hold or explained the resident's rights.

Three weeks later, on May 23, Resident 3 left on another therapeutic leave scheduled until May 27. Again, no documentation showed staff provided required bed-hold notices.

Staff E from social services told inspectors that Resident 3 "would leave often on therapeutic leaves" but said the department "did not provide bed holds to residents leaving on therapeutic leaves and were not aware of the requirement."

Federal regulations require facilities to provide written notification about bed-hold policies when residents leave on therapeutic absences. The notices must explain whether the facility will hold the resident's bed, for how long, and what happens if the resident wants to return after the hold period expires.

Without these notices, residents can lose their beds and face unexpected costs or displacement when they're ready to return from medical treatment or temporary stays elsewhere.

The inspection found that staff routinely ignored documentation requirements that protect residents during some of their most vulnerable moments – when transferring between care facilities or temporarily leaving for medical treatment.

The facility's own policies acknowledged the importance of discharge summaries, stating they must include post-discharge plans and be completed before any transfer. Yet when inspectors reviewed three residents' discharge planning, they found one resident transferred without any summary at all.

For Resident 2, the failure meant the receiving long-term care facility had no formal documentation of the person's care needs, medication history, or treatment plans beyond basic medical records. The blank discharge instructions provided no guidance for ongoing care.

The violations occurred despite clear facility policies requiring the documentation. The Transfer or Discharge policy, updated in October 2021, specifically assigned responsibility to nursing services and social services for preparing discharge summaries and completing discharge notes in medical records.

Staff interviews revealed the documentation failures weren't isolated incidents but part of routine practice. The director of nursing admitted they didn't always complete discharge summaries, while social services staff said they weren't aware residents had rights to bed holds during therapeutic leaves.

The inspection classified the violations as causing minimal harm or potential for actual harm to a few residents. But the failures left residents without critical protections during care transitions and temporary absences – times when proper documentation and rights notifications are most essential for continuity of care and protection from unexpected displacement.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Woodard Creek Health & Rehabilitation from 2025-09-04 including all violations, facility responses, and corrective action plans.

Additional Resources

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