F0628

D

Failure to Notify Long-Term Care Ombudsman of Involuntary Discharge

Shelton, Washington Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency when the facility failed to notify the Long-Term Care Ombudsman of a resident’s discharge. The resident was admitted with diagnoses including an ankle infection, mood disorder, and substance abuse, and a Minimum Data Set dated 01/04/2026 documented that the resident was cognitively intact. Following a verbal altercation with a nurse and concerns about aggression, verbal abuse toward staff, and the smell of alcohol on the resident, the facility issued a Transfer and Discharge Notice dated 02/18/2026, citing endangerment to the safety of others due to the resident’s clinical or behavioral status. The notice indicated it was given to the resident on 02/17/2026 with a discharge date of 02/19/2026, and the Recapitulation of Stay documented that the resident was being discharged to a shelter.

During interview, the resident reported being told by the Social Service Director that they had to leave after the altercation and believed the discharge was not optional. The resident stated they did not know where to go, and the Social Service Director said they would work on a location, later providing a pamphlet that led the resident to believe they were going to another facility or senior housing, rather than a homeless shelter. The resident described being dropped off by the facility van at a homeless shelter, finding the doors locked, and learning there were no beds available for the night, after which they sought help from family. Record review on 02/25/2026 showed no documentation that the Long-Term Care Ombudsman had been notified of the discharge, and the Social Service Director acknowledged in interview that they had not sent the Transfer and Discharge Notice to the Ombudsman, stating they send such notices at the end of the month. This failure was cited under WAC 388-97-0120(5)(b).