The resident's healthcare power of attorney sent increasingly frustrated emails to facility staff throughout early September, asking for medication lists, therapy reports, and a care plan that never came. Meanwhile, the resident's medical records showed staff had stopped critical medications and ordered IV fluids for 48 hours of hydration, but no one notified the designated decision-maker.
"It was very frustrating," said the resident advocate who attended a care conference on August 29. Staff couldn't answer the family's questions during that meeting either.
The breakdown in communication started immediately after the resident's admission. Electronic medical records showed no notification went to the healthcare power of attorney when medications were discontinued, lab work was ordered, or IV hydration began. The care conference held on August 29 discussed "multiple issues regarding the resident's admission, medication management and progress," but the family left without answers.
By September 4, the healthcare power of attorney was emailing the care team with a list of specific concerns. They wanted to know the resident's plan given that insurance was ending, an assessment of current condition, the medication list, and final reports from physical, occupational and speech therapy. The email revealed a fundamental problem: "CC1 did not know Resident 1's plan of care and it was not discussed in the care meeting."
Facility staff responded the same day but offered little substance, writing only that the family should "let them know if they still had concerns."
The next day brought another email from the increasingly worried family member. Questions from the previous day remained unanswered. They still hadn't received a care plan. "CC1 wrote it was a deep concern to them." They also asked about a swallowing issue from the evening before. Staff promised to schedule another care conference to address the remaining questions.
Nobody called.
Five days later, the healthcare power of attorney was following up about the promised care conference. They hadn't heard from staff.
The next day brought another email. Still no care meeting scheduled. Still no answers about medication status, therapy, or discharge planning. The family's frustration was evident in the written record: they were "upset at the lack of response to their questions and requests."
When federal inspectors arrived on September 17, they found a care system that had completely failed to include the resident's designated healthcare decision-maker. The resident care manager, a licensed practical nurse who had overseen the case since admission, admitted they had spoken to the healthcare power of attorney for the first time just one day earlier, on September 16.
The care manager said it was the responsibility of floor nurses to notify residents' representatives about changes in care. But the floor nurses never made those calls.
The Director of Nursing acknowledged the obvious when inspectors interviewed her that afternoon. She said families "should be notified of residents' clinical change of condition, medication changes and plan of care." When asked directly if the healthcare power of attorney should have received the resident's care plan, she said yes.
The Administrator was equally direct about the facility's failure. They "understood why CC1 was frustrated" and agreed the family "should have been involved in Resident 1's care since admission to include the plan of care and changes to their medications."
But understanding came too late. For weeks, a resident's healthcare power of attorney had been shut out of critical medical decisions while staff discontinued medications for diabetes and bipolar disorder, ordered IV hydration, and developed treatment plans in isolation. The family advocate who attended meetings left without answers. Emails went unanswered for days. Promised care conferences never happened.
The resident's medical records contained detailed notes about medication changes and treatment plans. The family's inbox contained increasingly desperate requests for the most basic information about their loved one's care. The two never connected until federal inspectors forced the conversation that should have happened on day one.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Olympic View Post Acute from 2025-09-17 including all violations, facility responses, and corrective action plans.