Staff at Encore Village failed to identify who held power of attorney for the resident, instead repeatedly calling the man's daughter who had explicitly told them to contact her fiancé. The mix-up left the actual decision-maker uninformed about multiple falls and the resident's declining health.
The resident was an elderly male admitted with moderate cognitive impairment, heart failure, atrial fibrillation, and a history of falling. Federal inspectors found the facility violated regulations requiring proper implementation of advance directives and power of attorney arrangements.
"I am R1's power of attorney, and the facility didn't let me know about R1's condition until the day R1 passed away," the son-in-law told inspectors. "They always contact V5; nobody informed me about R1's decline or about his multiple falls."
The confusion reached a breaking point when the resident returned from a hospital stay after signing out against medical advice and taking an Uber home. The daughter, frustrated by the situation, directly asked staff why they couldn't contact her fiancé who held the power of attorney.
"The daughter said she was tired of him and asked why the facility couldn't call my fiancé, who has the power of attorney," the facility's nurse practitioner told inspectors.
Despite this clear direction, staff continued their pattern of miscommunication. The social services director admitted uncertainty about who actually held decision-making authority. "I am not sure who was the power of attorney for R1. I will ask the administrator about the R1's POA," the social services director said.
The administrator acknowledged the facility never obtained proper power of attorney paperwork, yet staff had been documenting the son-in-law as the power of attorney in medical records. "We never got any power of attorney (POA) paperwork. V5 is the primary contact, so we were contacting V5. It was a mistake that staff were documenting V6 as R1's POA," the administrator explained.
This created a dangerous contradiction. While the facility's own records identified the son-in-law as the power of attorney, staff consistently bypassed him for all medical decisions and updates about the resident's condition.
The administrator attempted to shift responsibility to the social services department. "The social service has the sole responsibility to have the advance directive in place for our residents," the administrator said.
Federal inspectors found no written documentation in the resident's medical record designating either the daughter or son-in-law as power of attorney. The facility's own policy requires the Social Service Director to "assess, care plan and implement Advance Directives within 30 days after admission."
The policy defines a resident representative as "a person appointed as a decisional representative that is either designated in writing by a resident to be his or her power of attorney or the resident's healthcare surrogate or guardian."
The breakdown in communication had serious consequences beyond administrative confusion. The son-in-law remained unaware of his father-in-law's multiple falls and overall decline, preventing him from making informed decisions about care. The daughter, meanwhile, grew increasingly frustrated with being contacted about decisions she wasn't authorized to make.
The incident highlights how administrative failures can isolate families from critical medical information. When the resident signed out of the hospital against medical advice and returned via Uber, it represented exactly the type of situation where proper power of attorney notification becomes crucial for resident safety and family coordination.
Federal regulations require nursing homes to honor residents' rights regarding treatment decisions and ensure proper implementation of advance directives. The failure to establish clear power of attorney procedures violated these protections designed to keep families informed and involved in care decisions.
The facility's confusion persisted even during the federal inspection, with the social services director uncertain about power of attorney arrangements months after the resident's admission. This suggests the problem extended beyond a single case to systemic issues with advance directive implementation.
The son-in-law's exclusion from medical decisions continued until the most critical moment, when staff finally contacted him on the day his father-in-law died.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Encore Village from 2025-10-14 including all violations, facility responses, and corrective action plans.