Resident 3, who had congestive heart failure and advanced liver scarring, departed the facility on June 8 against medical advice. Progress notes show only that "the resident would not wait to take the facility stored medications" and "would be back to retrieve their belongings."
Seven weeks later, the resident told inspectors the facility "did not have medications sent to a pharmacy after they left" and that "they were forced out of the facility and did not want to leave."
Staff B, a facility employee, admitted the medical record failed to document efforts made to keep the resident at the facility. "She tried to get the resident to stay at the facility but did not write a note," according to the inspection report. The facility should have faxed medications to a pharmacy, "but she could not tell by reviewing the record if that was done."
The facility's own policy requires extensive safety measures for residents who leave against medical advice. Staff must educate residents on risks, notify the attending physician, document the provider's response, and review medications and treatments. Residents must sign a Release of Responsibility form, or staff must document and witness any refusal to sign.
None of this happened for Resident 3.
"There should have been a Release of Responsibility form completed but this was not in the medical record," Staff B told inspectors. "The record should explain everything that was done to make the discharge as safe as possible, but this was not reflected in Resident 3's record."
The pattern repeated with Resident 6, who had chronic lung disease and required oxygen. Progress notes from July 29 show the resident "is requesting to leave AMA" and that staff "notified Administrator and Family following facility protocol for AMA discharges."
But again, no Release of Responsibility form existed in the medical record.
Staff B acknowledged the same documentation failures. The record should have explained safety measures taken, "but this was not reflected" in the file.
A third case involved confusion over whether a resident's departure constituted an "elopement" requiring emergency protocols. Resident 5 signed out of the facility but never returned as expected, leaving staff uncertain about the resident's whereabouts.
Staff A told inspectors he "was not sure Resident 5's absence should have been considered an elopement because the resident signed out of the facility." However, he "admitted the resident did not return to the facility as expected and the staff did not know where the resident was for a period."
Staff B, who was off duty during the incident, said "she would consider this an elopement and feels elopement protocol should have been followed."
The facility's discharge policy, dated October 2021, explicitly requires staff to "make all reasonable efforts to ensure that the resident was educated on risks associated with leaving the facility without a physician's approval." The policy mandates that efforts "would be made to ensure the resident had safest discharge possible."
For residents with serious medical conditions like congestive heart failure or oxygen dependence, leaving without proper medication arrangements and safety planning creates immediate health risks. Congestive heart failure means the heart cannot pump blood effectively enough to meet the body's needs. Chronic obstructive pulmonary disease causes ongoing lung damage.
The inspection found these safety protocols repeatedly ignored. Required forms went uncompleted. Medication transfers to pharmacies either didn't happen or weren't documented. Staff admitted the medical records failed to reflect safety measures that should have been taken.
Resident 3's experience illustrates the human impact. Seven weeks after leaving, they remained without proper medication access and felt they had been "forced out" rather than making an informed decision to depart against medical advice.
The violations affected multiple residents across several months, suggesting systemic failure rather than isolated incidents. Staff acknowledged knowing the requirements but failing to follow them, then failing to document what limited efforts they did make.
State inspectors classified the violations as having potential for actual harm to residents. The facility's own employees recognized the documentation failures and missing safety protocols during interviews, but the problems had persisted for months without correction.
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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