Raven v. Department of Social & Health Services
306 P.3d 920, 177 Wash.2d 804 (2013)
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Rule of Law:
A guardian's good-faith determination to honor a ward's previously expressed wish to refuse nursing home placement cannot be the basis for a finding of neglect. For a pattern of conduct to constitute neglect, substantial evidence must demonstrate a nexus between the guardian's professional shortcomings and the physical harm suffered by the ward.
Facts:
- In 1996, Ida, an elderly woman with numerous debilitating ailments and a history of preferring alternative medicine, became bedbound after a fall.
- Ida was consistently resistant to traditional medical care and combative with caregivers, and had consistently expressed a wish to remain in her home rather than be placed in a nursing facility.
- In March 2004, Resa Raven was appointed as Ida's limited guardian and determined in good faith that Ida, if competent, would oppose being placed in a nursing home.
- Throughout the guardianship, Ida's care was complicated by her own combativeness, her husband's inconsistent administration of pain medication, and chronic staffing shortages from the care agency, Catholic Community Services (CCS).
- Ida suffered from severe, recurring pressure sores (bedsores) due to difficulties in repositioning her, an action that caused her pain and required two people.
- In May 2006, the home health agency, Assured, withdrew its services because Ida's behavior was too combative for its staff, leaving Ida temporarily without a primary care physician.
- In November 2006, a new hospice team, Providence, noted the severity of Ida's bedsores and recommended 24-hour nursing home care.
- Raven respected Ida's wishes and did not pursue nursing home placement, but did unsuccessfully attempt to have Ida involuntarily committed after a designated mental health provider determined Ida did not meet the criteria.
Procedural Posture:
- The Department of Social and Health Services (DSHS) made a founded finding of neglect against guardian Resa Raven.
- An Administrative Law Judge (ALJ) held a hearing and reversed the DSHS finding.
- A DSHS review judge reinstated the finding of neglect based on a pattern of conduct.
- Raven appealed to the Pierce County Superior Court (a trial court), which reversed the neglect finding.
- DSHS, as appellant, appealed to the Court of Appeals of Washington, Division Two. Raven was the respondent.
- The Court of Appeals reversed the superior court, thereby reinstating the neglect finding.
- Raven, as petitioner, petitioned the Supreme Court of Washington for review, which was granted. DSHS is the respondent.
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Issue:
Does a guardian's pattern of conduct constitute neglect when she honors her ward's good-faith determined wish to remain at home despite a deteriorating medical condition, and where the guardian's professional shortcomings are not substantially linked to the ward's resulting physical harm?
Opinions:
Majority - Stephens, J.
No, the guardian's conduct does not constitute neglect. A guardian’s good-faith decision to honor a ward's opposition to nursing home placement is protected by statutes prioritizing the ward's autonomy and cannot be the basis for a neglect finding. The court reasoned that under Washington law (RCW 7.70.065 and RCW 11.92.190), a guardian must follow the 'substituted judgment' standard, doing what the ward would do if competent, rather than a 'best interests' standard. Since DSHS found as fact that Raven made a good-faith determination of Ida's wishes, she was legally bound to honor them. While Raven did exhibit professional shortcomings, such as infrequent in-person visits and a vague understanding of Ida's medical needs, there was no substantial evidence showing a nexus between these failings and Ida's harm. The court found that the primary obstacles to Ida's care—her own combativeness, family interference, and severe staffing shortages—were largely beyond Raven's control, and it rejected imposing a strict liability standard on guardians for such outcomes.
Analysis:
This decision significantly clarifies the high bar required to find a guardian neglectful, particularly when a ward's right to self-determination conflicts with their medical needs. It strongly affirms the 'substituted judgment' standard over the 'best interests' standard, protecting guardians who honor a ward's known wishes even if it leads to a medically adverse outcome. The ruling establishes that a finding of neglect requires more than just professional shortcomings; there must be a clear, evidence-based link between the guardian's specific failures and the harm suffered. This precedent provides crucial protection for guardians in complex cases where factors beyond their control, such as client non-compliance or systemic resource shortages, impede ideal care.
