F0627

D

Failure to Ensure Safe AMA Discharge and Required Notifications

Snohomish, Washington Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

Surveyors found that the facility failed to ensure a safe discharge plan for one resident who left the facility against medical advice (AMA). The resident had moderate cognitive impairment, impaired vision, and used a front-wheeled walker. A recent hospital discharge summary documented that psychiatry had determined the resident did not have decisional capacity and that the resident’s son was the surrogate decision maker. The facility’s transfer/discharge policy required evidence of discussion with the resident to make an AMA departure a safe discharge. On the date in question, the resident signed out of the facility in the Patient Sign In & Out Log but did not sign back in, and later told a nurse by phone that they were staying in a motel and did not want to return, except possibly to retrieve belongings.

Record review showed no discharge instructions or discharge summary in the resident’s EHR, and no documentation that the resident’s emergency contact, provider, or Adult Protective Services (APS) had been notified. Multiple staff, including RNs, Social Services, and the Administrator, described that their usual process when a resident leaves AMA or stays out overnight includes educating the resident on risks, ensuring safety, notifying the Administrator, Social Services, APS, the provider, and the resident’s emergency contact, and documenting these actions in progress notes. Social Services staff also stated they would attempt to arrange home health services, instruct the resident to contact their primary care provider, and provide resources, with all steps documented in the EHR. However, staff were unable to provide any documentation that these steps were taken for this resident, and there was no evidence in the progress notes of APS notification or other required communications related to the AMA discharge.