St. Elizabeth Rehab: Advance Directive Failures - MD
Three months later, when the resident became confused and two physicians declared them incapable of making informed medical decisions, nobody at the facility could identify who was authorized to make choices on their behalf.
Resident #5 scored 14 on a cognitive screening test during admission on May 25. Scores between 13 and 15 indicate someone is "cognitively intact" and capable of understanding medical decisions. The admission record listed the resident as their own "Responsible Party."
But the advance directive section of their admission paperwork sat blank.
Federal inspectors found no evidence that St. Elizabeth staff asked whether the resident had existing advance directives. They found no documentation showing staff informed the resident about their right to create advance directives. No records indicated the facility offered assistance in establishing these legal documents that specify medical preferences when someone can no longer communicate them.
The resident's condition deteriorated over the summer. By August 5, confusion had increased significantly enough that two physicians evaluated their mental capacity. Both doctors certified that Resident #5 could no longer make informed medical decisions.
That's when the facility's failure became critical.
With the resident now unable to consent to or refuse treatments, St. Elizabeth staff couldn't determine who held the legal authority to make medical decisions. The medical record contained no documentation identifying a surrogate decision-maker. No process had been followed to establish who could speak for the resident.
When federal inspectors requested all documentation related to Resident #5's advance directives and decision-maker determination on August 29, the administrator scrambled to find answers. An hour and fifty minutes later, he returned with an explanation: the resident hadn't brought advance directives to the facility upon admission.
But that missed the point entirely.
Federal regulations require nursing homes to inform all residents about advance directives during admission, regardless of whether they arrive with existing documents. Facilities must explain residents' rights to create these directives and offer assistance in developing them. For residents who are cognitively intact, this represents a crucial opportunity to document their wishes before any decline occurs.
The administrator asked for more time to locate evidence that staff had offered the resident information and assistance with advance directives. He also promised to provide documentation showing how the facility determined a surrogate decision-maker after the resident lost capacity.
Two and a half hours later, he returned empty-handed.
He told inspectors he couldn't find any additional documentation. The social worker who had been employed during the resident's admission no longer worked at St. Elizabeth, he explained, as if that somehow excused the missing records.
The failure created a dangerous vacuum of authority. When residents lose decision-making capacity without advance directives or identified surrogates, medical teams face uncertainty about everything from routine treatments to emergency interventions. Family members may disagree about care decisions. Legal guardianship proceedings can drag on for weeks while medical conditions deteriorate.
Resident #5's case illustrates how a simple admission oversight can cascade into a complex ethical and legal problem. What began as blank paperwork during a routine admission became a fundamental question: who speaks for someone who can no longer speak for themselves?
The timing made the failure particularly troubling. Resident #5 had been cognitively intact for months after admission. Staff had multiple opportunities to address advance directive planning during that period. Social workers typically revisit care planning as residents adjust to facility life. Nurses conduct regular assessments that could have flagged the missing documentation.
Instead, everyone waited until the resident could no longer participate in the conversation.
St. Elizabeth's inability to produce basic documentation about such a fundamental resident right suggests deeper problems with admission procedures and record-keeping. The departure of the social worker who handled the admission doesn't eliminate the facility's responsibility to maintain complete records about resident rights and preferences.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" to "few" residents. But for Resident #5, the consequences were immediate and ongoing. Every medical decision now required navigation of an unclear authority structure that could have been established months earlier with proper admission procedures.
The resident remains at St. Elizabeth, still confused, still lacking identified decision-makers. The blank advance directive section from their admission record has become a blank space in their medical autonomy, created by a facility that failed to fulfill one of its most basic obligations to informed residents who trusted it with their care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St. Elizabeth Rehabilitation & Nursing Center from 2025-08-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 6, 2026 · Our methodology
ST. ELIZABETH REHABILITATION & NURSING CENTER in BALTIMORE, MD was cited for violations during a health inspection on August 29, 2025.
Resident #5 scored 14 on a cognitive screening test during admission on May 25.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.