The facility raised the resident's lithium dosage by 50 percent to treat worsening hallucinations and delusions, but failed to notify Maine's Department of Health and Human Services, which serves as the resident's full guardian and conservator.
The resident's public guardian representative told inspectors during a January 28 phone interview that Oak Grove's primary provider had increased the lithium dose "without obtaining the Guardian's consent." Court records show the state was appointed as the resident's full guardian in October 2018.
On September 30, 2025, the facility's provider increased the resident's lithium from 300 milligrams twice daily to 450 milligrams twice daily. The clinical record contained no evidence that staff discussed this dosage change with the guardian or obtained consent for the medication adjustment.
Lithium is a mood stabilizer and antimanic agent used to treat bipolar disorder and other psychiatric conditions. The resident's care plan, last updated September 11, specifically noted that a "State guardian will be involved with decisions being made."
The care plan also identified the resident as being "at risk for complications related to the use of psychotherapeutic medication" and included an intervention to "provide informed consent to R1 or healthcare decision maker."
Oak Grove's social worker described the facility's notification process to inspectors on January 29. The social worker said that "for any change in condition or need to send a resident out, nursing is to call and get approval of the guardian, specifically for anything requiring a decision."
But the guardian discovered the medication change only after it had already been implemented.
In an October 2, 2025 email to Oak Grove staff, the guardian expressed frustration with the facility's failure to follow proper consent procedures. "A phone call with a voicemail or email notification of what is going to be done does not constitute consent," the guardian wrote.
The guardian continued: "I found out today that R1's Lithium was changed and I was not previously made aware of this, nor was I asked for consent on this."
The email emphasized the legal reality that made guardian consent mandatory: "R1 is unable to provide his/her own consent which is why the State of Maine is his/her guardian."
This wasn't the first time Oak Grove had failed to obtain proper consent for treatment decisions involving this resident. The guardian's October email referenced "the facility's failure to obtain consent for treatment and medication changes," suggesting a pattern of violations.
Federal regulations require nursing homes to ensure that residents' representatives can exercise the residents' rights when the residents cannot do so themselves. For residents with court-appointed guardians, this means obtaining guardian consent before making significant medical decisions.
The inspection classified the violation as causing "minimal harm or potential for actual harm," affecting few residents. However, the failure to obtain consent for psychiatric medication changes represents a serious breach of resident rights protections.
Lithium requires careful monitoring due to its narrow therapeutic window and potential for serious side effects. The medication can cause kidney problems, thyroid dysfunction, and neurological complications, making informed consent particularly important for dosage changes.
The resident's guardian holds both conservatorship and guardianship powers, meaning they control not only financial decisions but also personal and medical choices. The 2018 court appointment gave the state comprehensive authority over the resident's care decisions.
Oak Grove's administrator discussed the finding with the surveyor on February 24, but the inspection report does not detail any corrective actions taken by the facility.
The violation occurred despite Oak Grove having written policies acknowledging the need for guardian involvement in resident care decisions. The resident's care plan explicitly stated that the state guardian should participate in decision-making processes.
For this resident, who experiences hallucinations and delusions severe enough to warrant increased psychiatric medication, the guardian's oversight provides crucial protection in medical decision-making when the resident cannot advocate for themselves.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Grove Center from 2026-01-29 including all violations, facility responses, and corrective action plans.