Raven v. Dep't of Soc. & Health Servs.

Citation: Not availableDocket: 87483-2

Court: Washington Supreme Court; July 18, 2013; Washington; State Supreme Court

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The Washington Supreme Court reviews a case involving Resa Raven, who was found to have neglected her ward, Ida, an elderly incapacitated person, by the Department of Social and Health Services (DSHS). The Court of Appeals upheld the neglect finding, but the Supreme Court reversed it, ruling that a guardian's good-faith assessment of a ward's opposition to nursing home placement cannot constitute neglect, as state law prohibits placing incapacitated individuals against their will. The Court also found no substantial evidence supporting the claim that Raven met the statutory definition of neglect. Although Raven's actions were not deemed neglectful, the Court noted that DSHS's actions were justified, denying Raven's request for attorney fees under the Equal Access to Justice Act.

Ida became bedbound at 75 due to a fall and suffered from multiple serious health issues, including chronic pain and dementia. Her history indicated she was resistant to medical care and exhibited problematic behavior towards caregivers. After being adjudicated incapacitated in 2004, Raven was appointed as her guardian. She familiarized herself with Ida's medical history and, based on her understanding of Ida's consistent refusal of nursing home care, opted for a care plan that allowed Ida to remain at home. Raven worked to address Ida's lack of a primary care physician, facing challenges due to Ida's combative behavior and financial constraints.

In August 2005, Raven held a care conference primarily to address the absence of a primary care physician for Ida. Following this, Ida was admitted to the emergency room due to bedsores, leg pain, and the need for a doctor. Post-discharge, she was assigned a team from Assured Home Health and Hospice, which included a physician. In November 2005, Assured convened another conference to discuss the return of Ida's pressure sores, attributed partly to insufficient repositioning by CCS's caregivers. Ida resisted being turned due to pain, complicating caregiver efforts. Although the care plan mandated repositioning every two hours, staffing shortages made this impractical, especially since Ida required two caregivers for assistance. Concerns were raised about Richard, Ida's husband, not consistently administering her pain medication, further complicating her care. Raven decided to postpone any remedial actions until after the holidays to avoid adding stress to the family.

In January 2006, it was agreed that CCS would implement a more aggressive repositioning program, with assistance from Assured staff. A request for additional personal care hours was submitted to DSHS, which was approved in February or March 2006. This led to a period of relative stability in Ida's condition. Discussions about hiring independent care providers arose as a potential solution to staffing gaps; however, DSHS authorized only one additional hour of care for two aides. The ALJ deemed it speculative that independent providers could be found for the unstaffed hours, a finding upheld by the review judge. Raven ultimately opted against this solution, feeling unprepared to supervise independent providers.

In May 2006, Ida's condition deteriorated when Assured withdrew from her care due to issues with medication management by Richard, which made Ida's behavior unmanageable. This withdrawal resulted in the loss of her physician. Raven sought guidance from the Thurston County Superior Court, which suggested out-of-home placement, conflicting with Ida's preferences. Raven did not pursue the court's recommendation to hire an attorney to either terminate CCS or ensure compliance with the care plan by all caregivers, despite acknowledgment that she had the authority to replace CCS. The court also mentioned the possibility of involuntary commitment, which Raven did not follow up on for several months.

In June 2006, a care conference involving CCS evaluated the agency's ability to meet Ida's care needs, leading to a suggestion for nurse delegation certification for CCS workers to administer Ida’s medications. Paperwork was filed for this certification. During this time, Raven sought a refill for Ida's pain medication from a nurse practitioner friend and searched for a primary care physician. In mid-August, Raven took Ida to the emergency room due to a lack of pain medication and managed to secure an October appointment with a doctor at Sea-Mar Clinic, resulting in a new hospice team from Providence Home Care/Hospice. Despite having no bedsores initially, Ida's condition worsened by November 15, 2006, leading to serious bedsores. Raven communicated with Providence's medical social worker, Linda Monterastelli, about Ida’s deteriorating condition and agreed to support hospitalization if recommended. Monterastelli suggested 24-hour nursing care, but Raven was hesitant to authorize it against Ida's wishes and proposed involuntary commitment, which the designated mental health provider (DMHP) rejected. A severe winter storm in December caused power outages at both Raven's and Ida's homes, further worsening Ida's condition. After the storm, Monterastelli contacted Adult Protective Services (APS) for assistance, leading to an investigation by APS investigator Glenda Specht, who determined Ida needed emergency care. With Raven's consent, Ida was hospitalized on December 30, 2006, after CCS terminated its services. Ida was later transferred to a rehabilitation center, where she stabilized but ultimately passed away on April 24, 2007. DSHS found Raven negligent, citing a pattern of neglect, particularly during the storm. An administrative law judge initially reversed this finding, but a DSHS review judge reinstated it regarding the pattern of neglect, excluding the storm period. The Pierce County Superior Court reversed the pattern of neglect finding, but the Court of Appeals reinstated it, leading to a petition for review by Raven.

The court is examining the Department of Social and Health Services (DSHS)'s finding of neglect against Raven, which was upheld by a review judge. DSHS investigates neglect allegations involving vulnerable adults, defined under RCW 74.34.020(17) as individuals unable to care for themselves, including court-ordered incapacitated persons. Neglect is characterized by a failure to provide necessary goods and services for maintaining the physical or mental health of a vulnerable adult, or by actions that disregard potential harm to them, as outlined in RCW 74.34.020(12). The DSHS review judge confirmed Raven's neglect based on evidence that her actions either failed to provide necessary care or prevent harm.

The Administrative Procedure Act (APA) outlines that an agency order can only be invalidated under specific conditions in RCW 34.05.570(3), with the burden of proof on the party claiming invalidity. Appellate courts review legal conclusions de novo and factual findings under the substantial evidence standard. 

A key issue raised by Raven is that a guardian's good-faith decision not to place an incapacitated individual in a nursing facility, against the individual's wishes, should not constitute neglect. Despite Ida's complex care needs, Raven advocated for Ida's consistent preference against nursing home placement when competent. DSHS acknowledged Raven's good-faith determination of Ida's wishes. The complexities of substitute decision-making for incapacitated individuals are highlighted through a reference to *In re Guardianship of Ingram*, where the court sought to clarify decision-making processes for incapacitated wards regarding life-prolonging treatments, emphasizing that decisions should reflect what the ward would choose if competent.

The focus is on determining what an individual would choose if competent, rather than applying a reasonable person standard. Courts must assess decisions based on the ward's specific attitudes and preferences. RCW 7.70.065(1)(c) mandates that before a guardian can give informed consent on behalf of an incompetent patient, they must ascertain in good faith whether the patient would consent if competent. If this cannot be established, consent can only be granted if the proposed health care aligns with the patient's best interests. Additionally, RCW 11.92.190 prohibits the involuntary detention of an incapacitated person in a residential treatment facility without proper legal authority. In light of these statutes and Ida's expressed preferences, Raven decided against pursuing out-of-home placement for Ida. However, the Court of Appeals deemed Raven's actions neglectful, arguing that she failed to balance Ida's wishes with her medical necessities. The court criticized Raven for allowing Ida's historical opposition to residential care, influenced by delusions, to take precedence over her urgent medical needs. The case illustrates that merely respecting a ward's expressed desires cannot justify neglecting critical medical care. Raven contends that the Court of Appeals' stance risks mischaracterizing guardianship responsibilities regarding institutionalization, a view the court agrees with.

The Court of Appeals' ruling conflicts with Ingram and RCW 7.70.065, as evidence shows that Raven, acting in good faith, determined that Ida consistently opposed traditional medical care and preferred to die at home. A reviewing court is not permitted to challenge this finding. The Court of Appeals suggested that Raven should have further assessed Ida's stance on nursing home placement once in-home care became inadequate. DSHS argues that Raven's belief was solely based on Ida's historical opposition to nursing homes. Under RCW 7.70.065, a guardian must ascertain a ward's wishes if competent; if this is impossible, the guardian may act in the ward's best interests, which likely favored a nursing home in this case. Raven's good-faith determination of Ida's wishes is supported regardless of whether it was based on historical or current factors. DSHS contends Raven should have asked Ida about her stance during critical moments, but evidence indicates that Ida's hostility toward caregivers suggests she would not have accepted a nursing home placement. The review judge found it speculative to assume that a better rapport would change Ida's refusal. The Ingram court emphasized that a ward's choices do not need to align with what is broadly considered prudent. The Court of Appeals' reasoning contradicts Ingram and RCW 7.70.065, and therefore, is rejected. Furthermore, even if Raven had disregarded her good-faith assessment, she could not have placed Ida in a nursing home without involuntary commitment, which was not deemed necessary by the mental health professional assessing Ida. Thus, Raven acted in accordance with RCW 7.70.065 and RCW 11.92.190 by not seeking out-of-home placement, making the Court of Appeals' neglect finding erroneous. DSHS has alternative avenues for addressing concerns about guardians, including oversight by the Certified Professional Guardian Board and the ability to seek protective orders under RCW 74.34.110.

Substantial evidence does not support the conclusion that Raven's actions amounted to neglect of her ward, Ida. The DSHS review judge determined that Raven, once committed to in-home care for Ida, had a duty to meet Ida's needs. The judge found that Raven failed to educate herself on residential care options, understand Ida's medical conditions—particularly her need for repositioning—make sufficient in-person visits, or seek independent providers for care. These deficiencies led to inadequate pain management, repositioning, and personal care for Ida over several months. 

Raven contended that her ability to provide care was hindered by external factors, including a lack of qualified care providers and Ida's resistance to care. The analysis focuses on whether Raven's conduct met the legal and professional standards expected of guardians, as outlined in RCW 11.92.040 and RCW 11.92.043, which mandate that a guardian must prioritize the ward's rights and best interests while providing care in the least restrictive environment. 

The review judge found that Raven's actions fell short of these standards, particularly in her lack of knowledge regarding residential care options and medical issues related to Ida. The judge emphasized that informed consent for medical care requires a guardian to be knowledgeable about the ward’s medical needs, which Raven failed to demonstrate, particularly regarding Ida’s repositioning needs to prevent bedsores. Despite these findings, the conclusion of neglect is ultimately deemed unsupportable.

Raven's infrequent visits with Ida, totaling only five in 2006 and just two at home, impaired her understanding of Ida's medical needs, as noted by the review judge. Under CPG standard 401.15, a guardian is required to maintain meaningful, in-person contact with the incapacitated individual, which Raven failed to do. Consequently, important care decisions were not made due to Raven's lack of personal observation of Ida's deteriorating condition in late 2006. The review judge highlighted that CPG standard 401.6 obligates guardians to recognize their limitations and ensure qualified care providers are involved, which Raven neglected by not pursuing independent providers due to her lack of experience in supervising staff.

The review judge also suggested that Raven should have terminated her guardianship under CPG standard 407.2 when it became evident she could not secure a primary care physician or adequate staffing for Ida's care plan. However, the judge did not find any legal requirement for Raven to guarantee that Ida accepted the arranged care. Raven’s responsibility was to provide care in the least restrictive environment suitable for Ida, respecting her rights and preferences. Evidence indicated that when Ida was cooperative, such as periods without bedsores, the care arrangement was effective.

The review judge concluded that Raven acted in good faith and with Ida's best interests in mind, particularly noting a positive relationship between Ida and her caregiver, Pam Hernandez. CPG standard 404.5 does not impose a duty on guardians to ensure acceptance of care plans by their wards, and the court rejected the notion that guardians should be held to a strict liability standard regarding their wards' acceptance of care. Furthermore, the review judge misinterpreted CPG standard 404.5 when claiming that Raven failed to secure an appropriate residential placement for Ida.

CPG standard 404.5 mandates that Raven ensure residential placements for Ida prioritize physical comfort and safety, which she attempted to fulfill. However, the care agency's inability to cover all of Ida's staffing hours was beyond her control. The review judge noted Raven's obligation to explore and evaluate alternative residential placements, finding substantial evidence that she did not adequately perform this duty, particularly regarding temporary options that could have provided better care. Additionally, Raven had a responsibility to provide informed medical consent for Ida but exhibited only a vague understanding of Ida's medical needs.

The judge also referenced CPG standard 401.15, which requires guardians to maintain meaningful contact with their wards, including in-home visits. Evidence indicated that Raven made minimal visits in 2006, especially during times when Ida faced significant medical challenges. While the ideal frequency of visits varies by situation, an expert indicated that Raven would have benefited from seeing Ida at least monthly.

Although DSHS claimed that another agency expressed interest in caring for Ida, it was unclear whether that agency could adequately staff her care, particularly for challenging hours. The record suggested that this agency could not provide staffing when requested later by CCS. Raven acknowledged the need for more frequent visits but the review judge incorrectly concluded that she failed to seek independent care providers or step aside as guardian if she felt unable to supervise them. Raven's choice not to pursue independent providers aligned with CPO standard 401.6, which recognized her limitations, and DSHS found it speculative whether independent providers would have improved Ida's care given her resistance to caregiving. The judge's citation to CPO standard 407.2 to support the conclusion about stepping aside was deemed unpersuasive.

CPO standard 407.2 applies when a guardianship must be terminated due to a change in the incapacitated person's status, such as regaining capacity. A guardian is not obligated to end their role simply due to personal decisions regarding potential actions that may not align with their expertise. The findings regarding Raven's duties indicate that she failed to conduct adequate research on Ida's residential options, did not stay informed about Ida's medical needs, and lacked meaningful in-person interactions with Ida to assess her situation and caregiver relationships.

DSHS concluded that these shortcomings constituted neglect under RCW 74.34.020(12), which defines neglect as a pattern of conduct that fails to provide necessary goods and services for a vulnerable adult's health or prevents harm to them. The review judge's determination of neglect is contested, as it lacked substantial evidence; the record does not support that Raven’s actions resulted in a failure to provide necessary care or caused harm to Ida.

While Raven's conduct was deemed inadequate from a professional perspective, it did not meet the threshold for neglect as defined by law. Evidence indicated that Ida received the available services, and there was no finding that Raven denied her necessary medical attention. Although alternative residential placements may have provided more comprehensive services, the current arrangement was consistent with Ida's preferences and the least restrictive option available. The assessment of whether Raven's actions prevented physical harm to Ida remains more nuanced.

Raven's failure to consider alternative temporary placements for Ida is noted, with Ida's bedsores improving at a rehabilitation facility, though she ultimately passed away there. The outcome of her returning home remains speculative, as her skin issues fluctuated in severity both at home and in care. There is no evidence indicating that Raven's knowledge deficit regarding bedsores led to neglect of medical recommendations. Staffing issues and Ida's behavior impeded her care, unrelated to Raven's knowledge. While Raven's infrequent visits are concerning, she maintained regular communication with Ida's caregivers, demonstrating attentiveness to their concerns, which diminishes the link between her visits and Ida's decline. The statute RCW 74.34.020(12) requires a connection between the alleged neglect and the guardian's actions, yet the evidence does not substantiate that Raven's shortcomings caused harm or failure to provide necessary services to Ida. Conversely, Raven made reasonable efforts to secure medical care and address staffing issues.

Regarding attorney fees, the superior court awarded Raven fees under the BAJA, which mandates such awards for prevailing parties unless the agency action is deemed substantially justified or an award would be unjust. Substantially justified means the agency's actions were reasonable in law and fact, and the court's decision on attorney fees is reviewed for abuse of discretion. Given the case's outcome, further discussion on the necessity of proving harm under RCW 74.34.020(12)(a) is unnecessary.

A trial court abuses its discretion if its decision is manifestly unreasonable or based on untenable grounds. In this case, the superior court found that the Department of Social and Health Services (DSHS) acted without substantial justification, but did not provide reasons for this conclusion. The appellate court determined that, given the record, the trial court's decision was untenable, as DSHS could reasonably pursue its actions despite any shortcomings exhibited by Raven as a guardian. The appellate court emphasized that the legislature intended fee-shifting statutes to protect citizens from inappropriate agency actions. However, it was concluded that DSHS's actions, although ultimately unsupported, were substantially justified, leading to the reversal of the trial court's fee award to Raven. The court acknowledged the difficult circumstances surrounding the case but found no evidence to support a neglect finding against Raven under the relevant statute. Therefore, the appellate court reversed DSHS's finding of neglect and denied Raven's request for attorney fees.