Raven v. Dep't of Soc. & Health Servs. ( 2013 )

Fl L E
l~l CLERKS OFFICE
Ronal, .
Supreme Court Clark
IN THE SUPREME COURT OF THE STATE OF WASHINGTON
RESARAVEN,
Petitioner, NO. 87483-2
v.
ENBANC
DEPARTMENT OF SOCIAL and HEALTH
SERVICES,
JUL 18 2013
Filed - - - - - - -
Respondent.
STEPHENS, J.-The Department of Social and Health Services (DSHS)
made a finding of neglect against guardian Resa Raven based on events that took
place during Raven's guardianship of Ida, an elderly incapacitated person. 1 Raven
challenges this finding, which the Court of Appeals affirmed. Raven v. Dep 't of
Soc. & Health Servs., 167 Wn. App. 446, 273 P.3d 1017 (2012). We reverse the
Court of Appeals and hold that a guardian's good-faith determination that her ward
opposes nursing home placement cannot be the basis for a finding of neglect in
1
Mindful of the confidentiality provisions of RCW 74.34.095, only Ida's first
name, and the first names of her family members, is used here. In addition, Raven was
formerly known as Eileen Lemke-Maconi, and some of the testimony and exhibits
contained in the record address her as such.
Raven (Resa) v. Dep't of Soc. & Health Servs., 87483-2
light of the legislature's clear mandate against placing incapacitated persons
against their will. We further hold that substantial evidence does not support the
conclusion that Raven's conduct otherwise met the statutory definition of neglect.
Finally, although the evidence does not support a finding of neglect against Raven,
DSHS's actions were substantially justified, and we therefore deny Raven's
request for attorney fees under the equal access to justice act (EAJA), RCW
4.84.350(1 ).
FACTS AND PROCEDURAL HISTORY
Ida became bedbound in 1996, at the age of 75, after a fall fractured a bone
in her knee. Ida suffered from several serious and debilitating ailments, including
muscle contractures that locked her legs in a splayed position, incontinence,
rheumatoid arthritis, dementia, and hallucinations. She experienced severe and
chronic pain. An adult protective services (APS) report in 2001 found that Ida, a
retired nurse, had a "'long history and lifestyle pattern of independence and
reliance on naturopathic and alternative medicine."' Administrative Record (AR)
at 104-05 (Review Decision and Final Order of DSHS, Finding of Fact 20)
(quoting Ex. 67, at 1). 2 After her fall, this pattern continued. Ida was resistant to
medical care and was combative, violent, hostile, and uncooperative with her
caregivers, including her husband Richard, her daughter Cheryl, and caregivers
2
In this opinion, the record compiled at the administrative hearing will be cited as
Administrative Record (AR). The testimony taken at the administrative hearing will be
cited as Administrative Report of Proceedings (ARP). Citations to the Clerk's Papers
refer to the record created by the Piece County Superior Court in its review of the agency
action.
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from Catholic Community Services (CCS). Her history between 1996 and 2004 is
rife with episodes of self-neglect, problems with her caregivers, and medical crises.
A significant area of medical concern for Ida after becoming bedbound was
pressure sores. Pressure sores (also variously known as skin breakdowns, pressure
wounds, pressure ulcers, or bedsores) occur when a bony protrusion under an
individual's skin (for example, the tailbone) has prolonged contact with a surface.
Frequent repositioning of a bedbound individual is required. Pressure sores are
exacerbated by lack of timely personal hygiene such as infrequent cleansing after
bowel movements or urination. Left untr~ated, bedsores can become severe and
life-threatening.
In 2004, at the age of 83, Ida was adjudicated incapacitated. Raven, a
licensed mental health counselor and a certified professional guardian, was
appointed Ida's limited guardian of person in March 2004. Ida was Raven's first
ward. As a Medicaid dependent, Ida had very little income, and Raven was
allowed fees of up to $17 5 per month for her services as a guardian. See AR at 111
(Finding of Fact 38). 3 Raven spent time after her appointment as guardian
familiarizing herself with Ida's history and medical situation. Based on her review
of Ida's history and conversations with Ida's family, Raven determined that Ida,
when competent, consistently refused to be placed in a nursing home or other long-
3
Although the finding of fact was that Raven could collect up to $17 5 a month in
fees, her testimony at her hearing was that DSHS authorized a monthly fee closer to $70.
ARP at 540.
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term care facility. Accordingly, Raven consented to a plan of care on Ida's behalf
that kept Ida in her home.
When Raven assumed the guardianship, Ida's personal care continued to be
provided by CCS, which contracted with DSHS through DSHS's agent, Thurston
County Area Agency on Aging (AAA). AAA provided case management. When
Raven was appointed, Ida had no primary care physician, and Raven began
working to resolve this issue. It was difficult to find a physician for Ida given her
combative history, her lack of ambulation, and her financial resources. 4 In August
2005, Raven convened a care conference to discuss several issues, foremost of
which was the lack of a primary care physician. Shortly after the conference, Ida
was taken to an emergency room due to bedsores, leg pain, and the need for a
doctor. As part of the hospital's discharge plan, Ida was paired with a team from
Assured Home Health and Hospice (Assured), which included a physician.
In November 2005, Assured convened a care conference to address the
reemergence of Ida's pressure sores, which Assured felt were caused in part by
CCS's caregivers not turning Ida enough. Ida was resistant to repositioning
because it caused her pain, which in turn led to reluctance on the part of her
caregivers to turn her. All of Ida's plans of care called for repositioning every two
hours, but due to staffing shortages, this was not an attainable goal, particularly
4
As a result of being bedbound, Ida's muscles had atrophied to the point where
she could not sit up. In order to leave her bed to see a doctor, she had to be transported
by gurney in an ambulance. See AR at 98 (Finding of Fact 5), 108 (Finding of Fact 34);
ARP at 558. Raven testified that Medicaid would not pay for ambulance transport for a
routine visit. I d.
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because Ida needed two people to turn her. Assured also had concerns, shared by
Raven, that Richard, Ida's husband, was not consistently administering Ida's pain
medication, which exacerbated the difficulty staff had in repositioning Ida. Raven
decided that any remedial steps should wait until after the holidays, reasoning that
the holidays would be stressful enough for the family without additional
disruptions to Ida's care.
At a follow-up conference in January 2006, it was agreed that CCS would
embark on a more aggressive turning program with training from Assured staff on
repositioning techniques. Following the meeting, a request for more personal care
hours was made to DSHS with the idea that this would enable a more aggressive
turning program. The request was granted in February or March 2006.
A period of relative calm in Ida's medical status followed the January 2006
conference. During this time, in early 2006, Ida's AAA case manager discussed
with Raven the possibility of hiring independent care providers as a way of filling
gaps in CCS's care staffing. AR at 122 (Finding of Fact 61). Independent
providers contract directly with DSHS, and it is the responsibility of the
patient/client or her guardian to hire and supervise the independent providers, as
opposed to caregivers provided by an agency like CCS, which supervises its
employees. DSHS authorized approximately one additional hour of paid care for
two aides. The administrative law judge (ALJ) concluded it was speculative that
independent providers could have been found for the care hours CCS could not
staff, given the difficulties associated with Ida's case. The review judge adopted
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this finding. AR at 122 (Finding of Fact 62). Additionally, Raven decided against
this option because she did not feel equipped to supervise such providers. AR at
123 (Finding of Fact 62).
In May 2006, Ida's situation destabilized again when Assured quit as a result
of the medication management in Ida's home. Without consistent administration
of Ida's pain and anxiety medication by her husband, Assured felt Ida's behavior
became too combative for staff to manage and that staff was at risk of harm.
Assured's exit from Ida's care team also meant she lost her physician. Raven
petitioned the Thurston County Superior Court for direction on what steps to take
next, but the court's advice-to seek an out-of-home placement-ran afoul of Ida's
wishes. Raven did not pursue the court's other suggestion: to retain an attorney to
petition for an order granting Raven leave to fire CCS or to assist in compelling
Ida's caregivers (including Richard) to cooperate with her plan of care. See AR at
1544-45 (Ex. 29, at 11-12). There was some acknowledgement in the colloquy
that Raven already had the authority to replace CCS. See AR at 1546 (Ex. 29, at
13). The court also suggested Raven look into involuntary commitment; Raven did
not pursue this option for several months.
A June 2006 care conference was convened with CCS to discuss whether the
agency could continue to meet Ida's needs. The idea of getting nurse delegation
certification for CCS workers was suggested, which would allow them, rather than
Richard, to give Ida her medication. The necessary paperwork was filed with
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DSHS for CCS workers to receive nurse delegation certification. 5 During this
period, Raven turned to a certified nurse practitioner friend to obtain a refill of
Ida's pain medication and also continued to look for a primary care physician for
Ida.
In mid-August 2006, Raven arranged to have Ida transported to the
emergency room because Ida had no more pain medication and still had no doctor
to prescribe a refill. On August 31, Raven was able· to get Ida an October
appointment with a doctor at Sea-Mar Clinic. As a result of the appointment, Ida
was assigned a new hospice team from Providence Home Care/Hospice
(Providence).
At the time Providence joined Ida's care team, Ida had no bedsores even
though during this time she did not have all of her care hours filled. See AR at
128. But by November 15, 2006, Ida's condition had deteriorated and she had
several very serious bedsores. !d. Between November 15 and December 14,
Raven had several calls with Providence's medical social worker, Linda
Monterastelli, about Ida's bedsores, though Raven did not go to see Ida. Raven
told Monterastelli that she would support Ida being taken to the hospital if that was
Monterastelli's recommendation. AR at 130. During these conversations in late
5
Unfortunately, the paperwork was lost by one of the agencies dealing with it and
nurse delegation was delayed. It was not quite in place when Ida went to the
rehabilitation center where she died, so this record is silent on whether it would have
made a difference in Ida's care. The ALJ and review judge made no express findings
about the impact of nurse delegation one way or another, and the review judge based no
conclusions of law regarding his finding of neglect against Raven on the basis that she
failed to diligently pursue nurse delegation.
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November 2006, Monterastelli shared her opinion that Ida needed 24-hour nursing
home care. AR at 129. Raven did not disagree but explained that she did not
believe she could authorize such a placement against Ida's wishes. Id. Raven
suggested to Monterastelli that they attempt to have Ida involuntarily committed
through a designated mental health provider (DMHP). AR at 129 (Finding of Fact
77). Monterastelli made an immediate referral to a DMHP, but the DMHP
concluded Ida did not fit the criteria for involuntary commitment. !d.
On December 14, 2006, a severe winter storm hit Thurston County. Both
Raven and Ida's homes were without power-Raven's for several days until
December 21 and Ida's intermittently between December 15 and 17. Raven was
unable to call out on a telephone or leave her house for several days. During the
power outages, Ida's condition took a turn for the worse when her special mattress
deflated, leaving her susceptible to worsened pressure sores. Due to Ida's rapid
deterioration following the power outages, at some point just after the storm
Monterastelli contacted APS to see if it could arrange 24-hour care for Ida. A
referral was made to APS investigator Glenda Specht. On or around December 29,
Specht made contact with Ida and determined her condition warranted emergency
care. With Raven's consent, on December 30 Ida was admitted to the hospital.
CCS gave notice it was terminating its services, and Raven consented to have Ida
transferred to a temporary rehabilitation treatment center on January 8, 2007.
Although she stabilized at the treatment center, Ida died on April 24, 2007.
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DSHS made a founded finding of neglect against Raven, alleging a pattern
of conduct or inaction that constituted neglect and also alleging that Raven's
conduct with regard to Ida during the December 2006 storm constituted neglect. 6
After a five-day hearing, an ALJ reversed the finding. A DSHS review judge
reinstated the finding as to the pattern of neglect but concluded that Raven's
actions during the winter storm, involving circumstances outside of Raven's
control, did not constitute neglect. AR at 169. This determination has not been
challenged by DSHS, and thus Raven's actions between December 14 and 21,
2006, are not at issue. 7 Pierce County Superior Court Judge Kitty-Ann
van Doorninck reversed the finding of neglect based on a pattern of conduct.
Division Two of the Court of Appeals reversed the superior court and reinstated
the neglect finding. A petition for review from Raven followed, which we granted.
ANALYSIS
This case reqmres the court to review DSHS 's substantiated finding of
neglect against Raven, as affirmed by an order of its review judge. DSHS is tasked
with investigating allegations of neglect against vulnerable adults, which includes
6
A founded finding is a determination made by agency staff. DSHS also alleged
that Raven's failure to transport Ida to the hospital following an August 2006
conversation with an AAA consulting nurse was neglect. The review judge disagreed,
and that original finding is not at issue. AR at 169.
7
The parties discuss the winter storm at length in their briefing. Likewise, several
findings of fact in DSHS's decision are devoted to it. To be clear, the time period
encompassing the storm is noteworthy only in that Ida took a turn for the worse to such a
degree that she ended up in the rehabilitation center where she died. In light of the
unchallenged findings, these events are not germane to the question of whether Raven
was neglectful.
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persons ordered incapacitated by the courts and elderly persons who are unable to
care for themselves. RCW 74.34.020(17). "Neglect" is
(a) a pattern of conduct or inaction by a person or entity with a duty of care
that fails to provide the goods and services that maintain physical or mental
health of a vulnerable adult, or that fails to avoid or prevent physical or
mental harm or pain to a vulnerable adult; or (b) an act or omission that
demonstrates a serious disregard of consequences of such a magnitude as to
constitute a clear and present danger to the vulnerable adult's health,
welfare, or safety, including but not limited to conduct prohibited under
RCW 9A.42.100.
RCW 74.34.020(12). Here, the DSHS review judge affirmed the finding of neglect
on the grounds that Raven's conduct met the criteria under both prongs of
subsection (a): a pattern of conduct or inaction that (1) failed to provide the goods
and services that maintain physical or mental health of a vulnerable adult or that
(2) failed to avoid or prevent physical or mental harm or pain to a vulnerable adult.
The Administrative Procedure Act (APA), chapter 34.05 RCW, guides an
appellate court's review of an agency order. An agency order may be invalidated
only if one of the circumstances contemplated in RCW 34.05.570(3) is present. 8
8
These criteria are
(a) The order, or the statute or rule on which the order is based, is in
violation of constitutional provisions on its face or as applied;
(b) The order is outside the statutory authority or jurisdiction of the
agency conferred by any provision of law;
(c) The agency has engaged in unlawful procedure or decision-
making process, or has failed to follow a prescribed procedure;
(d) The agency has erroneously interpreted or applied the law;
(e) The order is not supported by evidence that is substantial when
viewed in light of the whole record before the court, which includes the
agency record for judicial review, supplemented by any additional evidence
received by the court under this chapter;
(f) The agency has not decided all issues requiring resolution by
the agency;
(g) A motion for disqualification under RCW 34.05.425 or
34.12.050 was made and was improperly denied or, if no motion was made,
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The party asserting the invalidity carries the burden to show the invalidity. RCW
34.05.570(1)(a). The appellate court reviews de novo an agency's conclusions of
law and its application of the law to the facts. Tapper v. Emp 't Sec. Dep 't, 122
Wn.2d 397, 402, 858 P.2d 494 (1993). Findings of fact are reviewed under the
substantial evidence test and will be upheld if supported by '"a sufficient quantity
of evidence to persuade a fair-minded person of [the order's] truth or
correctness."' Port of Seattle v. Pollution Control Hr 'gs Bd., 151 Wn.2d 568,
588, 90 P.3d 659 (2004) (quoting King County v. Cent. Puget Sound Growth
Mgmt. Hr'gs Bd., 142 Wn.2d 543, 553, 14 P.3d 133 (2000) (quoting Callecod v.
Wash. State Patrol, 84 Wn. App. 663, 673, 929 P.2d 510 (1997))). With these
general standards of review in mind, we turn to the first issue presented by Raven.
A. A guardian's good-faith decision not to place an incapacitated person in a
nursing home against the incapacitated person's wishes cannot be the basis for
a finding of neglect
One of the difficulties of this case from the perspective of Ida's care team is
that Ida often required more care than could be delivered in a home setting. But in
matters of consent, though a ward may choose a course of action that would strike
many as unreasonable, if the guardian can determine that the ward would choose
such an action if competent, the guardian is bound to advocate for that position.
facts are shown to support the grant of such a motion that were not known
and were not reasonably discoverable by the challenging party at the
appropriate time for making such a motion;
(h) The order is inconsistent with a rule of the agency unless the
agency explains the inconsistency by stating facts and reasons to
demonstrate a rational basis for inconsistency; or
(i) The order is arbitrary or capricious.
RCW 34.05.570(3).
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, After investigating the issue of Ida's residential placement preferences, Raven
determined that when competent, Ida consistently refused to be placed in a nursing
home or other long term care facility. AR at 108 (Finding of Fact 32). DSHS
found that Raven's determination that Ida would not choose out-of-home care was
made in good faith. Id.Substitute decision-making on behalf of incompetent individuals poses
particular difficulties. In In re Guardianship of Ingram, 102 Wn.2d 827, 829-31,
689 P.2d 1363 (1984), a guardian sought a court order forcing a ward to submit to
a laryngectomy for cancer treatment when the ward's preference was for radiation.
Although the laryngectomy was far more likely than radiation to be successful at
putting the ward's cancer into remission, it would also most likely result in the
ward losing her vocal cords. This court acknowledged that the issue was one of
first impression: the proper procedure for determining whether an incompetent
person must submit to a life prolonging or curative treatment. Id. at 83 5. It sought
to provide the decision-maker-the court faced with the petition-with the factors
it should consider. Id. at 836-38.
In doing so, the court reiterated that the "goal is to do what the ward would
do, if she were competent to make the decision." Id. at 838. "The goal is not to do
what most people would do, or what the court believes is the wise thing to do, but
rather what this particular individual would do if she were competent and
understood all the circumstances, including her present and future competency."
Id. at 839. In other words, courts cannot apply a "reasonable person" test, but must
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apply a subjective test based on the ward's "attitudes, biases, and preferences." ld.
at 844.
RCW 7.70.065(1)(c) speaks directly to a guardian's duties. It requires that
[b]efore any person authorized to provide informed consent on behalf of a
patient not competent to consent under RCW 11.88.010(l)(e), other than a
person determined to be incapacitated because he or she is under the age of
majority and who is not otherwise authorized to provide informed consent,
exercises that authority, the person must first determine in good faith that
that patient, if competent, would consent to the proposed health care. If
such a determination cannot be made, the decision to consent to the
proposed health care may be made only after determining that the proposed
health care is in the patient's best interests.
(Emphasis added.) In addition, RCW 11.92.190 speaks to placing an incapacitated
person in institutional care. It mandates that
[n]o residential treatment facility which provides nursing or other care may
detain a person within such facility against their will. Any court order, other
than an order issued in accordance with the involuntary treatment
provisions of chapters 10.77, 71.05, and 72.23 RCW, which purports to
authorize such involuntary detention or purports to authorize a guardian or
limited guardian to consent to such involuntary detention on behalf of an
incapacitated person shall be void and of no force or effect.
In light ofRCW 7.70.065(1)(c), RCW 11.92.190, and Ida's preferences expressed
when competent, Raven determined that she could not pursue an out-of-home
placement for Ida.
The Court of Appeals, however, concluded that the neglect finding was
appropriate because Raven declined to pursue placement in a residential setting.
"In failing to aggressively pursue transitioning Ida from home care to residential
care, Raven was not balancing Ida's wishes against her medical needs; rather, she
was allowing Ida's historical opposition to residential care to override her critical
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medical needs." Raven, 167 Wn. App. at 467. The Court of Appeals further
explained its view:
This failure to balance Ida's needs against her stated desires is particularly
egregious when Raven knew or should have known that Ida's rejection of
medical care in 2004 was based on Ida's delusions that the caregivers were
"imposters," that her husband had fled to California, that the emergency
room doctor was not a doctor, and that St. Peter's hospital was not St.
Peter's hospital. Giving weight to Ida's principled decisions about the kind
of care she would want if competent does not include allowing her
delusions to control the care she actually needed. This is not a situation
where the guardian had to choose between a treatment with a high chance
of success that would cause permanent disability or a treatment with lower
odds of success without the disability. See In re Guardianship of Ingram,
102 Wash.2d 827, 829, 689 P.2d 1363 (1984). Rather, the decision here
was whether to continue with the failing home care program or more
aggressively pursue the alternative institutional care Ida needed.
!d. Raven urges this court to disapprove of the Court of Appeals decision to the
extent it suggests that guardians must institutionalize their wards or risk neglect
findings.
We agree with Raven. The Court of Appeals' reasoning is in tension with
the guidance provided under Ingram and RCW 7.70.065. While evidence indicates
that Ida had some delusions about institutional care settings, DSHS found that
Raven in good faith determined that Ida, when competent, had consistently rejected
traditional medical methods and had always expressed a preference to die at home
with minimal medical intervention. A reviewing court cannot second guess this
unchallenged finding of fact.
The Court of Appeals' opinion suggests that Raven "should have continued
to test the strength of Ida's opposition [to a nursing home placement] when it
became obvious that in-home care could not cope" with her medical needs. Raven,
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167 Wn. App. at 458. DSHS takes up this thread, arguing that nothing in the
record indicates Raven based her belief that Ida opposed a permanent nursing
home placement on anything other than Ida's historic opposition to such an
arrangement. Suppl. Br. ofResp't at 16. But as noted, RCW 7.70.065's substitute
judgment provision requires the guardian to determine what the ward would want
if competent. If that determination cannot be made, then the guardian may act in
the ward's best interests, which here likely favored placement in a nursing home.
Because it is established that Raven made a good-faith determination about
what Ida wanted if competent, it matters little whether Raven based her
determination on historic or contemporaneous facts (or both). The finding is that
Ida did not want to be placed in long-term care. DSHS insists that Raven should
have asked Ida at certain points-when her pressure sores were at their worst, for
example-whether she had reconsidered her opposition to a nursing home. Suppl.
Br. of Resp't at 16. Ida's continued hostility and violence toward her caregivers,
as demonstrated in this record, belies the suggestion she would have been willing
to accept a permanent nursing home placement if only Raven had asked her about
it. Indeed, the review judge concluded that it was speculative and not supported by
substantial evidence to assume that Ida would have eventually agreed to placement
if Raven had spent more time building rapport with Ida. AR at 149. 9 As the
Ingram court stated, it does not matter whether the ward's choice might not be
9
DSHS also argues that Raven was remiss in not asking Ida whether she would
agree to a temporary placement. This is a separate issue from a permanent nursing home
placement and is addressed in the section below.
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what most people would do or find prudent. To the extent that the Court of
Appeals' discussion is at odds with Ingram and RCW 7.70.065, we reject it.
Moreover, even if Raven had chosen to disregard her good-faith
determination of Ida's judgment in this matter, Raven could not have placed Ida in
a nursing home. RCW 11.92.190 prevents any person, whether competent or not,
from being placed against their will in a residential treatment facility unless they
have been involuntary committed under chapters 10.77, 71.05, and 72.23 RCW.
As noted, Raven pursued a possible involuntary commitment in late 2006, but the
designated mental health professional who assessed Ida determined she did not fit
the criteria for involuntary commitment.
In sum, DSHS made a finding of fact that Raven determined in good faith
that a permanent nursing home placement was against Ida's wishes, and nothing in
the record suggests that Ida had changed her mind. Raven therefore acted
consistently with both RCW 7.70.065 and RCW 11.92.190 by not pursuing such an
arrangement. To the extent that the Court of Appeals affirmed the neglect finding
based on Raven's decision not to pursue out-of-home placement, this was in error.
In light ofRCW 7.70.065 and RCW 11.92.190, Raven's good-faith determination
that an out-of-home placement is contrary to Ida's wishes cannot serve as the basis
for a finding of neglect. 10
10
We also note that a finding of neglect against a guardian is not DSHS's only
avenue of recourse. The Certified Professional Guardian Board also monitors the
activities of guardians and can initiate disciplinary proceedings against those who fall
short of the certified professional guardian standards. DSHS may also seek a protective
order against a guardian under RCW 74.34.110.
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B. Substantial evidence does not support the finding that Raven's conduct
constituted neglect
The DSHS review judge concluded that once Raven committed to in-home
care for Ida, Raven had a duty to ensure Ida's needs were met in the home. AR at
162. The review judge's conclusion that Raven failed to do so constituted the
grounds upon which he rested his order affirming the finding of neglect. AR at
168 (Conclusion ofLaw 56).
Specifically, he found that Raven failed to: educate herself on and regularly
explore residential alternatives; educate herself on Ida's medical conditions and
needs (specifically, her need for repositioning); make an adequate number of
meaningful, in-person visits to Ida's home; and pursue independent providers as a
care solution or, alternatively, step aside as guardian if supervising independent
providers were beyond the scope of Raven's abilities. AR at 163-68. These
failings, concluded the review judge, resulted in Ida's inadequate pain
management, inadequate repositioning, and inadequate personal bath care for
several months. !d. at 168. The review judge concluded that Raven's "failure to
ensure these critical care needs were met did constitute a pattern of conduct or
inaction that failed to provide the services to maintain Ida's physical health and
failed to avoid and prevent physical harm to her." !d. (Conclusion of Law 56).
In response, Raven argues that her efforts were frustrated by factors beyond
her control, most notably the dearth of qualified care providers able to fulfill the
care hours authorized by DSHS and Ida's own combativeness and resistance to
care. Having concluded that Raven's decision not to pursue an out-of-home
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placement for Ida does not support a finding of neglect, we must decide whether
substantial evidence supports the conclusion that Raven's other conduct rose to the
level of neglect.
We begin by rev1ewmg a guardian's fiduciary duty to her ward. A
guardianship is "'a trust relation of the most sacred character."' In re
Guardianship of Eisenberg, 43 Wn. App. 761, 766, 719 P.2d 187 (1986) (quoting
39 AM. JUR. 2D Guardian and Ward§ 1 (1968)). A guardian owes a fiduciary duty
to her ward. Id.; Cummings v. Guardianship Servs. of Seattle, 128 Wn. App. 742,
755, 110 P.3d 796 (2005). A fiduciary duty means that "one party 'occupies such
a relation to the other party as to justify the latter in expecting that his interests will
be cared for."' Liebergesell v. Evans, 93 Wn.2d 881, 889-90, 613 P.2d 1170(1980) (quoting RESTATEMENT OF CONTRACTS§ 472(1)(c) (1932)).
The enumerated duties of a guardian are set forth in RCW 11.92.040 and
RCW 11.92.043. A guardian must, "[ c]onsistent with the powers granted by the
court, . . . care for and maintain the incapacitated person in the setting least
restrictive to the incapacitated person's freedom and appropriate to the
incapacitated person's personal care needs, [and] assert the incapacitated person's
rights and best interests." RCW 11.92.043(4). In addition to this statutory
mandate, a certified professional guardian's conduct is governed by the Standards
of Practice Regulations for certified professional guardians (CPG Standards).
Just as the review judge, we evaluate the claim of neglect against the
backdrop of the CPG Standards. With these standards in mind, we consider first
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whether the review judge correctly concluded that Raven failed to meet her
professional standards and then whether those shortcomings amounted to neglect.
While it is a close question, we conclude the finding of neglect is unsupportable.
1. Raven's Conduct as a Guardian
Under CPG standard 404.5, "[t]he guardian shall, to the extent possible,
select residential placements which enhance the quality of life of the incapacitated
person, provide the opportunity to maximize the independence of the incapacitated
person, and provide for physical comfort and safety." AR at 1836 (Ex. 38 at 4). 11
Under CPG standard 404.7, "[t]he guardian shall, as necessary, thoroughly
research and evaluate the incapacitated person's residential alternatives." Id. The
review judge concluded Raven did not abide by these standards: Ida received
substandard care for many of the months when Raven was her guardian, and Raven
shared a lack of knowledge about residential alternatives that may have been
legally permissible, such as general inpatient admission to a hospital or a
rehabilitation treatment center. AR at 163-64 (Conclusion of Law 48).
CPG standard 405, et al., requires the guardian to provide informed consent
for medical care on behalf of the ward. AR at 1836 (Ex. 38, at 4). The review
judge reasoned that informed consent means Raven had a duty to be
knowledgeable about Ida's medical conditions. AR at 164 (Conclusion of Law
49). He concluded that she failed in this duty as evinced by her testimony
11
We cite to the administrative record for the text of the standards because since
the time of the hearing, the standards have been renumbered. The parties' briefing cites
to the standards as they were numbered at the time of the hearing.
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demonstrating that she had only a vague understanding of Ida's need for
repositioning to avoid bedsores, and of bedsores in general, and did not know how
often Ida was being repositioned. !d. The review judge noted that Raven's
minimal visits with Ida contributed to her lack of understanding regarding Ida's
medical needs.
Under CPG standard 401.15, the guardian must have meaningful, in-person
contact with her client as needed, including observing the incapacitated person's
circumstances and interactions with care providers. AR at 1834 (Ex. 38, at 2). The
review judge opined that Raven fell far short of this standard, finding that Raven
visited Ida only five times in 2006, and only twice that year in Ida's home. AR at
112-13 (Finding of Fact 44). The review judge concluded that because Raven
"insulated herself from Ida's quickly deteriorating condition by failing to
personally observe the situation in late 2006, the necessary care decisions were not
made." AR at 167 (Conclusion of Law 53).
CPG standard 401.6 requires the guardian to "know and acknowledge
personal limits of knowledge and expertise" and to "assure that qualified persons
provide services to the incapacitated person." AR at 1833 (Ex. 38, at 1). Raven
failed in this duty, the review judge concluded, when she chose not to pursue
independent providers because she was not experienced in supervising such staff.
Alternatively, the review judge opined that Raven had a duty under CPG standard
407.2 to terminate her guardianship when it became clear she could not procure a
primary care physician or find enough staff to carry out Ida's care plan.
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Turning now to whether the review judge correctly determined that Raven
fell short of these standards, we first consider the review judge's general
proposition that having chosen in-home care for Ida, Raven had a duty to ensure
Ida received the goods and services she needed. The review judge did not identify
any law or standard that required Raven to ensure or guarantee that Ida accepted
the care Raven could arrange for Ida in Ida's home. Raven was required to care for
and maintain Ida in the setting least restrictive to Ida's freedom and appropriate to
her personal care needs and to assert Ida's rights and best interests. RCW
11.92.043(4). As found by DSHS, Ida's preference if competent was to remain at
home to die. This arrangement was least restrictive to Ida's freedom and asserted
her rights.
There was nothing inherently inappropriate about this arrangement with
.,
regard to Ida's personal care needs; had Ida been cooperative with the
repositioning program, nothing in the record suggests she would have developed
the serious bedsores she did. Indeed, the record reflects periods of time when Ida
did not suffer from sores, suggesting periods when the care arrangement was
"working" even without the additional aide hours being filled and without
repositioning every two hours. For example, the findings of fact, which give a
detailed account of Ida's battle with pressure sores, make no mention of sores after
January 2006 until November 2006. The record also does not suggest that Raven's
decisions to stay the course with the care plan were not made in good faith or were
not made with Ida's best interests in mind. For example, Raven determined that
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Ida had a good relationship with one of CCS 's pnmary caregivers, Pam
Hernandez, and that it was in Ida's best interests to make the care plan work with
CCS as the staffing agency. AR at 132-33 (Finding of Fact 86).
Neither did CPG standard 404.5 impose on Raven a duty to ensure Ida
accepted the services offered under her plan of care in the home. See AR at 183 6
(Ex. 38, at 4). CPG standard 404.5 required Raven to select residential placements
that provide for physical comfort and safety to the extent possible. This does not
require a guardian to succeed in overcoming problems with staffing beyond the
guardian's control, such as staffing shortages, the ward's extreme resistance to
care, or obstructionist tendencies by a ward's family. As both Raven and amici
argue, endorsing DSHS 's view that Raven had a duty to ensure Ida accepted the
care that was offered sets up an untenable standard for guardians akin to strict
liability. See, e.g., Br. of Amicus Curiae Washington Academy of Elder Law
Att'ys at 11. We reject the suggestion that guardians have a duty to ensure their
wards accept the care provided to them.
As to the remaining duties identified by the review judge, as noted, the
review judge misinterpreted CPG standard 404.5 when he concluded Raven had
failed to secure a residential placement that met Ida's needs. Again, CPG standard
404.5 required Raven to select residential placements that provide for physical
comfort and safety to the extent possible. She did so. It was beyond her control
that the care agency could not fill all Ida's staffing hours, particularly where the
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record indicates it was unlikely any care agency could have done so. AR at 132
(Finding of Fact 84-85). 12
The review judge was correct that Raven had a duty to research and evaluate
residential placement alternatives. And the evidence substantially supports his
view that Raven failed to carry out that duty. It appears from the record that she
never asked about whether there were temporary placement options short of
permanent residential placements that might have provided more care. See, e.g.,
Administrative Report of Proceedings (ARP) at 670 (testimony of Raven). The
judge was also correct that Raven had a duty to provide informed medical consent
on Ida's behalf, and substantial evidence supports his finding that Raven had only
a vague knowledge of Ida's medical needs. See, e.g., ARP at 668, 725-26
(testimony of Raven). Likewise, the review judge correctly invoked CPG standard
401.15, requiring a guardian to have meaningful in-person contact with her ward,
including in-home visits. Substantial evidence supports the review judge's finding
that Raven made minimal visits in 2006, including when Ida was experiencing
significant medical issues. The optimal number of visits for a guardian is based on
the unique circumstances of the situation, but Raven's guardianship expert
12
DSHS argues that in June 2006 "another agency expressed interest in working
with Ida, but Raven decided to continue using CCS." Suppl. Br. of Resp't at 11.
Although the record does indicate that Raven had talked with another agency about
providing care, nothing in the record indicates if that agency actually had the staff to
fulfill Ida's hours or the staff willing to work on weekends or after 5 p.m., which were the
difficult slots to fill for Ida. See AR at 132 (Finding of Fact 85). The record does
demonstrate that that same agency DSHS identifies as being available in June 2006 was
not able to provide staffing in December 2006 at CCS's request. See AR at 876 (Ex. 10,
at 58); ARP at 593.
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acknowledged that Raven would "have been better off' if she had seen Ida more
frequently, somewhere in the order of at least once a month. ARP at 643
(testimony of Thomas O'Brien).
However, the review judge erred when he concluded that Raven failed a
duty to pursue independent providers for Ida or a duty to step aside as guardian so
that someone could be appointed who would supervise independent providers.
Ironically, Raven's decision not to pursue the option of independent providers was
consistent with CPO standard 401.6, which required her to acknowledge her
personal limits. DSHS made an express finding that it was speculative whether
independent providers would have been available had Raven pursued the option,
let alone made a difference in Ida's care given her resistance to care giving. AR at
122-23. In addition, the review judge's citation to CPO standard 407.2 to support
his conclusion that Raven should have stepped aside if she did not feel comfortable
.supervising independent providers is unavailing. CPO standard 407.2 is applicable
to scenarios in which circumstances have changed such that the guardianship itself
must be terminated, i.e., the incapacitated person is no longer incapacitated. It
does not require a guardian to terminate her representation as guardian because she
decides not to pursue a course of action, whose success is speculative at best,
outside her knowledge and expertise.
Thus, we are left with three findings of fact and conclusions of law as to
Raven's duties and failings that are supported in fact and law: that Raven failed,
under the CPO Standards, in her duty to adequately research and regularly review
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Ida's residential options; failed in her duty to become and stay informed as to Ida's
medical needs; and failed in her duty to make meaningful, in-person contacts with
Ida that allowed her to observe Ida's circumstances and interactions with
caregivers. We must decide whether these failures amount to neglect under RCW
74.34.020(12), as addressed below.
2. Raven's shortcomings as a guardian and the neglect standard
DSHS concluded that Raven's failings as a guardian amounted to neglect
using the "pattern of conduct" prong of the neglect definition, which defines
neglect as
a pattern of conduct or inaction by a person or entity with a duty of care that [(1)]
fails to provide the goods and services that maintain physical or mental health of a
vulnerable adult, or that [(2)] fails to avoid or prevent physical or mental harm or
pain to a vulnerable adult.
RCW 74.34.020(12)(a). 13 We cannot disturb this determination unless, as Raven
argues, we determine that the review judge erroneously interpreted or applied the
law, or the decision is not supported by evidence that is substantial when viewed in
light of the record. Under this standard, we conclude that DSHS's review judge
erred in finding a pattern constituting neglect because the conclusion is not
supported by substantial evidence.
13
DSHS did not rely on the alternative definition of neglect, "an act or omission
that demonstrates a serious disregard of consequences of such a magnitude as to
constitute a clear and present danger to the vulnerable adult's health, welfare, or safety,
including but not limited to conduct prohibited under RCW 9A.42.100." RCW
74.34.020(12)(b ).
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As noted, substantial evidence in the record supports the review judge's
factual conclusions that Raven failed, under the CPG Standards, in her duty to
adequately research and regularly review Ida's residential options, failed in her
duty to become and stay informed as to Ida's medical needs, and failed in her duty
to make meaningful, in-person contacts with Ida that allowed her to observe Ida's
circumstances and interactions with caregivers.
But these instances do not sustain a finding of neglect under RCW
74.34.020(12)(a). This record does not establish that Raven's conduct-while
lacking in many respects from a professional standpoint-failed to provide the
goods and services needed to maintain Ida's physical health or that her conduct
resulted in physical or mental harm or pain to Ida.
As to the first subsection of the definition, because we conclude that under
this record Raven had no duty to pursue independent providers, Ida was offered the
goods and services that were reasonably available to her-that is, the agencies
serving her were providing as much staff as they could. AR at 132 (Findings of
Fact 84-85). There is no finding of fact that Raven denied Ida medical attention
when she required it. As to Raven's failure to explore alternative residential
placements, it is likely true that Ida would have had round-the-clock access to
goods and services in an out-of-home placement, but again, she had the goods and
services reasonably available in the setting least restrictive to her freedom and in
accordance with her wishes.
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The question of whether Raven's conduct failed to avoid or prevent physical
harm to Ida is closer. As to Raven's failure to explore alternative temporary
placements, it is true that Ida's bedsores improved at the rehabilitation facility that
she entered following the last severe bout with bedsores in December 2006. But,
Ida also died there, and thus we do not know what would have happened had she
returned home. Even when at home Ida went through periods where her skin
issues resolved and periods where they were acute. The record gives no reason to
conclude that pattern would not have continued even after Ida had returned from a
temporary placement outside the home. Nor is there evidence that Raven's
inadequate knowledge about the treatment of bedsores resulted in a failure to take
steps recommended by Ida's medical care providers when needed. And, there is
evidence that staffing issues and Ida's combative behavior were getting in the way
of her care plan, which is unconnected in this record to Raven's lack of knowledge
about bedsores.
Finally, the infrequency of Raven's in-person visits is very troubling. But
the record reflects Raven was in regular contact with Ida's caregivers and their
supervisors. Given that Raven was not herself a caregiver, and given that Raven
demonstrated attentiveness to the concerns and recommendations of the caregivers,
this record evinces no nexus between her infrequent visits and Ida's deterioration.
To be clear, the plain language of RCW 74.34.020(12) does not require that
the alleged perpetrator of neglect be the only actor with problematic conduct. But
the statute does require that the alleged perpetrator's actions or conduct fail to
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provide goods or services, or avoid harm to the ward. This is not a tort causation
standard, but it plainly requires a nexus. On this record, there is not substantial
evidence demonstrating that among the many forces at play here, Raven's
shortcomings as a guardian resulted in a failure to provide goods or services or
avoid harm to Ida. On the contrary, despite several professional missteps, the
evidence indicates that Raven was reasonably diligent in securing Ida's
medication, services from doctors and other health professionals, and worked with
the care agencies on the staffing shortfalls. 14
C. Raven is not entitled to attorney fees
The superior court that heard Raven's administrative appeal awarded her
attorney fees under the BAJA. Under that statute, "a court shall award a qualified
party that prevails in a judicial review of an agency action fees and other expenses,
including reasonable attorneys' fees, unless the court finds that the agency action
was substantially justified or that circumstances make an award unjust." RCW
4.84.350(1) (emphasis added). "'Substantially justified means justified to a degree
that would satisfy a reasonable person.'" Silverstreak, Inc. v. Dep 't of Labor &
Indus., 159 Wn.2d 868, 892, 154 P.3d 891 (2007) (quoting Moen v. Spokane City
Police Dep't, 110 Wn. App. 714, 721, 42 P.3d 456 (2002)). And, an action is
substantially justified if it had a reasonable basis in law and in fact. Aponte v.
Dep't of Soc. & Health Servs., 92 Wn. App. 604,623,965 P.2d 626 (1998)
14
Given our resolution of this case, we need not address Raven's remaining
contention about whether harm must be shown under RCW 74.34.020(12)(a).
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(quoting Sneede v. Coye, 856 F. Supp. 526, 530-31 (N.D. Cal. 1994)). That is, it
need not be correct, only reasonable. Pierce v. Underwood, 487 U.S. 552, 566 n.2,
108 S. Ct. 2541, 101 L. Ed. 2d 490 (1988). A trial court's award of attorney fees
under the equal access to justice act is reviewed for abuse of discretion. Plum
Creek Timber Co. v. Wash. State Forest Practices Appeals Bd., 99 Wn. App. 579,
595, 993 P.2d 287 (2000) (citing RCW 4.84.350). A trial court abuses its
discretion when it makes a decision that is manifestly unreasonable, based on
untenable grounds, or based on untenable reasons. Moreman v. Butcher, 126
Wn.2d 36, 40, 891 P.2d 725 (1995); see Plum Creek Timber Co., 99 Wn. App. at
595-96 (noting an agency's decision-making process "'involves the balancing of
sensitive, sometimes competing or conflicting interests in a controversial area and
requires analysis of close questions on which there is no clear precedent on
point'").
An agency action that is arbitrary and capncwus 1s not substantially
justified. Puget Sound Harvesters Ass 'n v. Dep 't ofFish & Wildlife, 157 Wn. App.
935, 952, 239 P.3d 1140 (2010). On the other end of the spectrum, RCW
4.84.350(1) contemplates that an agency action may be substantially justified, even
when the agency's action is ultimately determined to be unfounded. This may
occur, for example, when the agency's determination, though ultimately
unsupported by the evidence, was made on the best available evidence at the time
of the decision. Kettle Range Conservation Grp. v. Dep't ofNatural Res., 120 Wn.
App. 434, 469-70, 85 P.3d 894 (2003).
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Here, the superior court concluded DSHS 's actions were not substantially
justified. The court's order did not offer any reasons for its conclusion. Clerk's
Papers at 94. In the absence of an explanation by the trial court for its ruling, and
in light of the record here, we must conclude that the trial court made an untenable
decision. Regardless of whether Raven's conduct amounted to neglect, the record
is clear that Raven exhibited several significant shortcomings as a guardian. More
to the point, under the facts here, an agency would be reasonable in pursuing the
same course of conduct that DSHS followed. Part of the justification for a fee-
shifting statute like the EAJA is that the legislature wants to "ensure citizens a
better opportunity to defend themselves from inappropriate state agency actions."
Costanich v. Dep't of Soc. & Health Servs., 164 Wn.2d 925, 929, 194 PJd 988
(2008) (emphasis added). We are wary of upholding a fee judgment that suggests
the sort of facts we are faced with here do not create substantial justification to
pursue a neglect finding, particularly where there has been no determination that
DSHS's actions were arbitrary, willful, or capricious.
Accordingly, although Raven is the prevailing party in this action, we
conclude DSHS 's action was substantially justified, reverse the trial court's award
of fees at that level, and reject Raven's request for fees before this court.
CONCLUSION
This case poses a difficult set of facts in which it is undeniable that Ida's last
years were not comfortable or dignified. As DSHS recognized, "one could not
script a more trying case for caregivers, family members, public and private care
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Raven (Resa) v. Dep't of Soc. & Health Servs., 87483-2
agencies, courts, and guardians than the one at hand." AR at 158. And it is
without question that Raven could have made better decisions in some areas and
that she exercised poor judgment in meeting her mandates under professional
standards in others. But the evidentiary record here cannot sustain a finding that
these failings amounted to neglect on Raven's part under RCW 74.34.020(12)(a).
Accordingly, we reverse DSHS 's finding of neglect against Raven. As to attorney
fees, we reverse the superior court and hold that DSHS' s action against Raven,
while ultimately unsupported, was substantially justified, and that Raven is not
entitled to attorney fees.
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WE CONCUR:
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