The October 29 departure violated the facility's own policies requiring staff to prepare medications for discharge, provide required documents including discharge summaries, and complete post-discharge care plans to help residents adjust to new living situations.
Staff B, a Resident Care Manager and Licensed Practical Nurse, told inspectors on November 7 that discharge summaries and instructions should be completed in the facility's electronic health record system. But when she reviewed the resident's file with the surveyor, she found no discharge instructions or summary had been created.
"There were no discharge instructions or discharge summary in the EHR record," Staff B reported during the interview at 10:45 AM.
The facility's Transfer or Discharge policy, dated October 1, 2021, specifically assigns nursing and social services staff responsibility for obtaining discharge orders, preparing medications, and providing residents with required discharge documents. The policy also mandates completing post-discharge care plans.
None of this happened for Resident 1.
Administrator Staff A acknowledged the breakdown during an afternoon interview the same day. The resident "had left the facility" without discharge instructions or home health services being arranged, Staff A admitted. Those services weren't set up "until today when surveyor had brought it to their attention."
The admission revealed that administrators only began addressing the resident's discharge needs after federal inspectors identified the violation during their November 13 complaint investigation.
Federal regulations require nursing homes to ensure transfers and discharges meet residents' needs and preferences while preparing them for safe transitions. The requirements exist because improper discharges can lead to medical complications, medication errors, and dangerous gaps in care.
The inspection report doesn't detail what medical conditions the resident had or what medications they needed. But the facility's failure to provide any discharge planning left someone who required skilled nursing care to navigate their transition alone.
Against medical advice discharges present particular risks because residents leave despite professional recommendations to continue treatment. These situations require even more careful discharge planning to ensure residents understand their conditions and have resources to manage their care independently.
The October 29 progress note simply documented that "Resident 1 packed up their belongings and discharged AMA." No follow-up notes addressed the missing discharge requirements or efforts to contact the resident after they left.
Alderwood Post Acute & Rehabilitation operates as a skilled nursing and rehabilitation facility in Lynnwood, serving residents who need medical care and therapy services. The facility's own policies recognize the importance of proper discharge planning, requiring staff to evaluate equipment needs and coordinate with home health agencies.
The inspection found the violation affected few residents but created minimal harm or potential for actual harm. However, the failure placed residents at risk of unsafe discharges and medical complications, according to the surveyor's findings.
Staff B's acknowledgment that no discharge documentation existed in the electronic health record system suggests the oversight wasn't simply a paperwork delay. The resident left without the basic safety net that discharge planning provides.
The administrator's statement that home health services weren't arranged "until today" when the surveyor raised the issue indicates the facility made no effort to address the resident's post-discharge needs for weeks after they left.
Federal inspectors cited the facility under regulations requiring safe transfer and discharge procedures. The violation demonstrates how administrative failures can compromise resident safety even after they leave the facility's direct care.
The timing raises additional questions about the facility's discharge procedures. With nearly two weeks passing between the resident's departure and the administrator's acknowledgment of missing services, other residents may have experienced similar gaps in discharge planning.
Washington state regulations referenced in the citation require facilities to ensure proper discharge planning and coordination of care. The violation suggests systemic problems with how Alderwood handles against medical advice discharges.
The resident's decision to leave against medical advice created a challenging situation, but federal and state regulations still required the facility to provide appropriate discharge planning and documentation. The complete absence of these safeguards left the resident without critical support during a vulnerable transition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alderwood Post Acute & Rehabilitation from 2025-11-13 including all violations, facility responses, and corrective action plans.
Additional Resources
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