Columbia Crest Center

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

comprehensive assessment, dated 10/14/2025, showed Resident 2 was cognitively intact, required the assistance of one person for toileting, incontinent care, dressing, personal hygiene, and bathing, and was independent with their mobility by using an electric wheelchair.Review of the Weekly Interdisciplinary Discharge Planning Assessment, dated 08/14/2025, showed Resident 2 planned to stay at the facility as a long-term care resident once skilled therapy was completed.Review of the care plan, dated 10/13/2025, showed Resident 2 was able to go out in the community unsupervised and staff were to assist Resident 2 with appropriate preparations such as verifying the battery of their electric wheelchair was charged.Review of the nursing PN, dated 11/11/2025 at 10:51 AM, showed Resident 2 informed facility staff that they were incontinent of bowel and bladder during their outings from the facility, and they were aware this caused skin breakdown to their coccyx (tailbone). Resident 2 stated they preferred to be assisted with incontinent care and application of sav (skin healing ointment) upon their return.Review of the nursing PN, dated 12/10/2025 at 12:54 PM, showed Resident 2 signed themselves out of the facility for a Therapeutic Leave of Absence (LOA) on 12/07/2025 with the plan to return to the facility on [DATE REDACTED].Review of the nursing PN, dated 12/12/2025 at 4:19 PM, showed Resident 2 contacted the facility stating they wanted to return to the facility and had experienced a fall while they were out of the facility. The PN showed Staff B, Director of Nursing, advised Resident 2 they would need evaluated by ER (emergency room) physician before (the facility) can accept them back.Review of the nursing PN, dated 12/12/2025 at 7:55 PM, showed the facility was contacted by the local hospital ER, on behalf of Resident 2, inquiring about their return to the facility. The ER Licensed Nurse (LN) stated Resident 2 was evaluated for skin breakdown to their coccyx due to having diarrhea for the last three days. The PN showed the facility staff informed the ER LN that Resident 2 could not return to the facility until they were reviewed as a new resident referral for admission, and this could not be completed until the next day.During an interview, on 12/23/2025 at 1:10 PM, Staff A stated the reason Resident 1 was denied readmission to the facility was related to financials, and they considered Resident 1's discharge to the hospital to meet the requirement of a safe discharge. Staff A stated Resident 1's care needs had not significantly increased or changed.During an interview, on 12/23/2025 at 4:40 PM, Staff B stated they directed Resident 2 to be evaluated at the ER before returning to the facility to ensure they were medically stable. Staff B stated they did not know why Resident 2 was not permitted to return on 12/12/2025 after being evaluated at the ER.During an interview, on 12/24/2025 at 4:15 PM, Staff E, Market Resource Clinician, stated they believed the facility policy was to review residents as new admissions if their Therapeutic LOA lasted longer than three nights. Staff E stated they were concerned Resident 2 developed new health issues including a wound to their coccyx. Staff E stated that information should have been explained to Resident 2, and that was the basis of the decision not to allow Resident 2 to return to the facility on [DATE REDACTED].During an interview, on 12/24/2025 at 4:20 PM, Staff A stated they were unsure of Resident 2's desire or need to readmit to the facility as they had not spoken with them. Staff A stated Resident 2's friend/caregiver had contacted the facility inquiring about Resident 2's mail, and they believe (Resident 2) is with them. Reference: WAC 388-97-0120(2-3), -0160(5)

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