Court: Court of Appeals of Washington; March 27, 2012; Washington; State Appellate Court
The Department of Social and Health Services (DSHS) determined that Resa Raven, a court-appointed limited guardian, neglected her ward, Ida, by not providing necessary medical services to maintain Ida's health and prevent harm. Although an administrative law judge initially found no neglect, the DSHS Board of Appeals reversed this ruling, concluding that Raven's inattention constituted neglect under the abuse of vulnerable adults act. The superior court later overturned the Board's decision and awarded Raven attorney fees, prompting DSHS to appeal. The appellate court affirmed the Board’s findings, stating that while Raven was not required to guarantee effective care, she was obligated to make reasonable efforts to meet Ida's medical needs. The evidence supported the Board's conclusion of neglect. The court also rejected Raven's claim that DSHS needed to prove neglect by clear and convincing evidence, asserting that a preponderance of the evidence was sufficient. Additionally, DSHS's actions were deemed substantially justified, leading to the reversal of the trial court’s attorney fees award to Raven.
Ida, born on April 15, 1921, suffered from numerous health issues including fractured fibula, muscle atrophy, incontinence, pressure ulcers, and dementia. Despite receiving in-home care from Catholic Community Services and case management from the DSHS's Area Agency on Aging, Ida exhibited hostile and uncooperative behavior towards caregivers and resisted medical treatment frequently. Concerns regarding her self-neglect were raised multiple times, culminating in a 2004 investigation by Protective Services that confirmed her refusal of medical care. DSHS subsequently petitioned for guardianship due to these concerns and the inability of Ida's family to make competent decisions on her behalf.
The superior court appointed Jan Carrington as a guardian ad litem (GAL) for Ida, leading to a mental health evaluation that revealed Ida was delusional, believing her husband, the emergency room doctor, and the hospital were not who they claimed to be. Based on the GAL's recommendation, the court appointed Raven, a licensed mental health counselor and professional guardian, as Ida’s limited guardian on March 12, 2004. Raven was given the authority to consent to or refuse medical treatment and make decisions regarding care providers, as mandated by RCW 11.92.
Raven reviewed Ida’s medical records, discussed her psychological issues with the GAL, and collaborated with various care agencies and Ida's family. She noted that Ida inconsistently responded to medical treatment and resisted nursing home placement. Although Raven initially visited Ida frequently, her visits decreased once Ida entered hospice care. Raven maintained a partial log of her actions on Ida’s behalf.
In November 2004, the Aging Agency assessed Ida and found significant health issues, including 10 pressure ulcers, and recommended bi-hourly repositioning, which caregivers resisted due to Ida's pain. A subsequent assessment in August 2005 indicated the need for emergency care due to open sores and a potential urinary tract infection, leading to Ida's discharge under hospice care with a life expectancy of less than six months.
Raven selected Assured Home and Hospice as the provider, resulting in a new primary care physician for Ida. By October 19, 2005, an assessment revealed only two pressure ulcers, but caregivers resisted instructions for more frequent repositioning. On November 17, Raven discussed concerns regarding caregiver cooperation and medication resistance with the Aging Agency and hospice staff, deciding to postpone discussions about changes until after the holidays to minimize stress. Ida's skin condition worsened in December 2005, and by January 2006, stage II pressure ulcers were documented. A care conference on January 10, 2006, acknowledged the worsening condition and the need for additional support and caregiver training.
In February 2006, Raven was urged by Ida's Aging Agency case manager to supplement care hours with independent providers, which she declined, preferring agency-supervised providers. The case manager noted the inadequacy of the current plan due to a shortage of workers, prompting Raven to suggest making the best of the situation. By May 16, 2006, hospice discharged Ida due to complications involving her husband, who failed to administer her medication properly. On that same day, Ida's hospice doctor resigned despite Raven's request for continued care. Subsequently, on May 30, 2006, Raven sought guidance from the Thurston County Superior Court regarding Ida’s care. The court initially indicated that institutional care was needed and suggested hiring an experienced attorney, a recommendation Raven did not pursue.
On June 16, 2006, during a meeting with Aging Agency and Catholic Services staff, Raven was tasked with finding a new physician. She requested staffing changes from Catholic Services, which agreed to provide training for caregivers to administer medications. Raven secured an advanced registered nurse practitioner to prescribe for Ida, but the nurse left for another job within a month. When Ida's medications ran out in August, Raven took her to the emergency room, where she struggled to find a new Medicaid-accepting doctor. Eventually, on August 31, 2006, Dr. Allison Spencer accepted Ida as a new patient. Raven communicated her urgent need for hospice or in-home nursing services to Dr. Spencer, who subsequently recommended a new hospice provider, Providence Home Care/Hospice.
When Providence took over in November 2006, Ida initially showed no signs of skin breakdown; however, she soon developed pressure ulcers. An Aging Agency representative indicated that Providence might terminate services, believing that Ida required nursing home admission. While Raven agreed with this assessment, she felt unable to act without a mental health professional confirming that Ida was eligible for involuntary detention. After arranging an assessment, the professional concluded that Ida's symptoms were primarily medical and not detainable. By November 2006, Raven still had not received the necessary nurse delegation due to lost paperwork, although the process was reportedly back on track.
By late November 2006, Ida's skin condition deteriorated, with pressure ulcers from stages I to IV observed by her hospice nurse, who recommended 24-hour care. The nurse identified that Ida's deflated mattress contributed to her skin breakdown, leading to the replacement with an air mattress. Although DSHS approved 280 hours of in-home care monthly, Catholic Services could only provide 189 hours, leaving gaps in care. A severe winter storm in mid-December caused power outages, during which Ida was found lying on the floor in urine, with some ulcers infected and progressed to stage IV. Raven, unable to assist due to fallen trees, consented to Ida's hospitalization on December 30, 2006. On January 5, 2007, Catholic Services ceased care, deeming it unsafe, and the Aging Agency considered terminating its services. With Raven's consent, Ida was moved to a rehabilitation center on January 8, 2007, where her condition improved until her death on April 24, 2007.
DSHS issued neglect notices to Raven in 2007 for failing to secure necessary medical care for Ida. After an investigation, DSHS found Raven neglected a vulnerable adult under RCW 74.34.020. Raven contested the finding in an administrative hearing, where the ALJ initially reversed DSHS's decision. However, the Board later affirmed the neglect finding, holding that Raven did not ensure Ida received adequate care and had a duty to be informed about Ida's medical needs. The Board emphasized that Raven should have regularly assessed Ida's care needs and considered transferring her to a nursing facility, especially given Ida's previous acceptance of such care after her fibula fracture in 1996. Raven's limited visit log reflected inadequate engagement, undermining her ability to address Ida's deteriorating condition effectively. The Board concluded that Raven's attempts to remedy the situation were insufficient, necessitating a proactive approach to ensure Ida's care needs were met.
Raven was found by the Board to have failed in her duty to procure independent caregivers for Ida, who required bi-hourly repositioning and timely personal care. The Board determined that Raven's lack of experience necessitated hiring qualified personnel. Despite being aware of Ida's medical issues, including the absence of a primary care physician and inadequate care from some caregivers, Raven did not take necessary action, which contributed to Ida's poor pain management and overall care. The Board noted that Raven's inaction led to significant neglect, evidenced by Ida’s deteriorating conditions, yet Raven claimed her responsibilities as a guardian were limited by specific statutes regarding patient consent, detention in care facilities, and nurse delegation laws. The superior court later reversed the Board's decision, awarding Raven $25,000 in attorney fees and costs, while noting that a reviewing court can overturn agency decisions on grounds of misinterpretation of law or lack of substantial evidence. Under the Abuse of Vulnerable Adults Act, neglect is defined as a failure to provide necessary care or a serious disregard for the consequences that jeopardizes the health and safety of a vulnerable adult. Raven argued that the Board misapplied the law regarding her duties as a guardian.
Raven asserts that various uncontrollable obstacles hindered her ability to provide adequate care for Ida, including restrictions on residential care, a mental health professional's refusal to commit Ida involuntarily, the loss of medical personnel, delays in nurse delegation, Ida's noncompliance with care, staffing difficulties, equipment issues, and adverse weather conditions. In contrast, DSHS contends that Raven had a duty to ensure Ida received necessary care and failed to do so through negligence, citing her lack of sufficient in-home support, inadequate monitoring of Ida’s condition, failure to seek treatment options, and neglect in medication administration.
A guardianship relationship is characterized by a fiduciary duty, requiring a guardian to ensure the incapacitated individual receives care in the least restrictive environment while advocating for their rights and needs. Washington law mandates that medical guardians create personal care plans, provide annual updates, and report significant changes in the ward's condition. Guardians are also obligated to ascertain the incapacitated person's health care preferences and ensure appropriate medical care, including preventive services.
Raven contends that DSHS must demonstrate that her actions directly caused harm to Ida to prove neglect, while DSHS argues that it can establish neglect by showing repeated failures to provide necessary care without needing to prove direct causation. DSHS maintains that evidence of Raven's shortcomings in securing appropriate medical care for Ida is sufficient to substantiate claims of neglect, given that Ida experienced pain and inadequate home care.
In a common law negligence claim, the plaintiff must establish that the harm resulted directly from the alleged negligence. Distinct from common law negligence, the act introduces a separate cause of action with its own standards for assessing misconduct. The Department of Social and Health Services (DSHS) must demonstrate a pattern of conduct that led to a deprivation of care, but it is not required to prove that this conduct caused harm to Ida or that alternative care plans would have been accepted by her. Raven, who managed Ida’s care, engaged with a team regarding Ida's home care plan, citing family turmoil and stress during the holidays as reasons for delaying changes. Despite worsening pressure ulcers and other medical issues, Raven did not consider independent caregivers or residential placement for Ida, who had been bedridden since 1996 and had a history of significant health problems. Although DSHS authorized additional care hours, agencies could not provide staff, and Raven did not actively pursue solutions, including consulting more experienced professionals about transitioning Ida to a residential facility. This failure to balance Ida's preferences with her medical needs ultimately resulted in neglect of her critical health requirements.
Raven failed to adequately balance Ida’s needs with her expressed desires, particularly regarding Ida's refusal of medical care in 2004, which was influenced by her delusions about caregivers and medical professionals. While it is important to consider Ida's preferences if she were competent, allowing her delusions to dictate her care was inappropriate. The critical decision was whether to continue the ineffective home care plan or pursue necessary institutional care. Despite being Ida’s guardian for 20 months, Raven neglected to act decisively, resulting in Ida’s worsening condition, including repeated hospitalizations for pressure ulcers and infections. Recommendations for residential care were ignored, and Raven's delayed responses persisted until Ida was admitted to rehabilitation in January 2007. The Board found Raven's inaction over two and a half years constituted neglect, rejecting her claims of insurmountable obstacles. Additionally, the Board upheld findings regarding Ida's poor nutrition and the need for repositioning every two hours, supported by substantial evidence from medical assessments and testimonies indicating that Raven was asked to hire independent caregivers due to failures in the existing care plan. The evidence established that poor nutrition and lack of repositioning directly contributed to Ida’s skin breakdown.
Raven failed to maintain in-person contact with Ida and did not adequately address her medical needs, which included bi-hourly repositioning, timely bathing, and medication administration. While the Board determined that Raven had a duty to meet these needs, the conclusions drawn were deemed too broad. The essential finding was that Raven's general duty was to provide all necessary care to Ida, and the specific actions characterized as duties were seen as evidence of her failure to fulfill that obligation.
Raven contended that her due process rights were violated when the administrative law judge required the state to prove neglect by a preponderance of the evidence instead of a higher standard, arguing that a neglect finding would jeopardize her employment prospects and counseling license. However, the evidentiary standard for establishing neglect is indeed preponderance of the evidence as outlined in WAC 388-71-01255(1), a standard consistently applied in similar administrative cases.
The court considered three factors to evaluate the need for a higher standard of proof: the private interest affected, the risk of erroneous deprivation, and the government's interest. It concluded that the administrative hearing's purpose was to establish neglect, not to revoke Raven's counseling license, despite Raven's claim that a neglect finding would effectively bar her from unsupervised work with vulnerable adults under RCW 74.39A.050(8). The court noted that it was unclear whether this finding would completely prevent her from practicing or just limit her work in certain areas, and found no legal precedent equating a neglect finding with a license revocation.
Ultimately, the court affirmed the Board’s final order and reversed the superior court's decision, including the award of attorney fees to Raven. The decision referenced Raven by her current name, acknowledged confidentiality provisions for Ida, and provided a definition of pressure ulcers, which are injuries caused by prolonged pressure on the skin.
Two primary instances of alleged neglect by Raven are highlighted: (1) in August 2006, she opted not to take Ida to the emergency room despite signs of a potentially broken leg, and (2) in December 2006, she failed to contact Ida for several days during power outages caused by a storm. An expert witness noted that while Washington law does not prescribe a specific number of visits, increased frequency would have been beneficial. The Board's findings regarding Raven's specific duties, such as frequent visitation and knowledge of Ida's treatment, are viewed as evidence of her broader obligation to provide necessary care, rather than duties that must be strictly adhered to. Raven's challenge to finding of fact 59 is noted, but both parties reference finding of fact 62, allowing for a waiver of technical violations under RAP 10.3(g). Unchallenged findings of fact remain valid in appeals from administrative rulings. The Administrative Law Judge (ALJ) must determine if there's a preponderance of evidence supporting claims of neglect towards a vulnerable adult, as per WAC 388-71-01255(1). A related case, Kraft v. Department of Social & Health Services, affirmed that the standard of proof for neglect under chapter 74.34 RCW is also preponderance of the evidence. The State contends that a finding of neglect should not equate to license revocation; however, unlike Kraft, Raven’s case involves her professional license, and a finding of neglect could affect her ability to maintain that license.
