Consent to Care Facility Admission & Long-Term Care Capacity Assessment (BC)

In British Columbia, consent is required before one can be admitted to a care facility. Cognitive impairment or dementia, may cause a decline in memory, reasoning, planning and judgement, and make one incapable to decide if they require such an admission. Thus, if incapacity is suspected, a patient's capacity for consent to a care facility needs to be assessed.

  • Adults can only be admitted to a licensed care facility with their informed consent.
  • If they are found to be incapable of making the decision, informed consent must be obtained from their substitute decision maker.

Due to recent changes in 2019 to the Health Care (Consent) and Care Facility (Admission) Act, allied health professionals such as social workers and occupational therapists can now also do long-term care capacity assessments.


The mnemonic HOMES can be used remember things to ask about when doing a capacity for care facility admission assessment.
  • H - Home supports
  • O - Overwhelmed/care giver burden
  • M - Medical issues and medications
  • E - Eating
  • S - Safety

When doing the assessment, consider:

  • Baseline function
  • What is the amount of change over time?
  • Underlying medical conditions
    • Which require medications?
    • Which do not require medications?
  • Nutrition
  • Collateral
  • Risks to the patient
    • Falling
    • Wandering
    • Not following up with medical treatments
  • Risks to others
    • Fires
    • Floods
    • Aggression/violence
  • What is the willingness to accept help?

Silberfield & Fish (1994) identify 6 distinct elements as comprising intolerable risk:[1]

  1. A change in the person that impairs his/her ability to protect themselves from harm
  2. Evidence of manifest failure
  3. Gravity of the anticipated harm
  4. Imminence of the anticipated harm
  5. Imposition of the risk on others
  6. Inability to choose to accept to be at risk

There are several core issues that can affect competency, including:

  1. Dependency: this is accentuated when capacity for self-care is diminished, when cognition is impaired, when illness and/or the threat of death are present.
  2. Ability to detect deception
  3. Entitlement, hope, and loss
    • Entitlement reflects one’s value of investment in life
    • Individuals may cling to the belief they can achieve some compensation which provides relief for their losses
    • False hope and entitlement distorts choice, and it emphasizes unrewarded value

Capacity vs. Competency

  • Capacity is defined as: “the degree to which one is able to understand information relevant to a decision and to appreciate the reasonably foreseeable consequences of a decision or lack of a decision.
  • Competency is defined as: “a property or characteristic that a person possesses which enables them to appreciate the reasonably foreseeable consequences of a decision or lack of a decision.”
  • Medical and legal definitions for competency differ. In the medical definition, a continuum is implied and fluctuation over time is expected. As a legal definition, a dichotomous distribution is inherent (i.e., one either is, or is not, competent) and a particular point in time is implied. These terms are often used interchangeably. In court and legal settings, the legal definition prevails.
  • Don not use the word “deem” – as this is a legal word
  • Instead, state:
    • “In my opinion the patient is [capable]/[not capable] of …”
    • “Given current resources and the patient's lack of insight, it would not be safe for them to live independently.”
  • The assessor should make it clear that this is an opinion only
  • There are several pieces of legislation that are involved once an opinion is made that a patient cannot consent to housing decisions:
    • Mental Health Act
    • Guardianship Act
    • Consent Act
    • Patients Property Act (PPA)
    • Representation Act
  • Practically, speaking, though each one of these acts may be used, the Consent Act and PPA are the main ways of carrying out housing incapacity.

Sample Documentation of Long Term Care Capacity Assessment (Incapacity)

We discussed where the patient would go after discharge from hospital. The patient understands that his son is unwilling to have him return home and he will need a new place to live. The patient is hopeful that he can “find a house and live on my own.”

The patient seemed unbothered when I informed the patient that they cannot afford a place to live in the city based on their current monthly income. The patient replies that he will “find a way.” When asked to elaborate, the patient was vague and unable to. When we discussed that they had previously had a fall and were unable to call for help or 911, they did not recall this. The patient was also not able to appreciate that there were burnt pots on his stove from his attempts to cook, and could not appreciate the risks of a fire or serious injury.

When asked how he would afford utilities and groceries in addition to rent, the patient said “I don't need to eat much.” He declines the suggestion of a long-term care facility, stating, I do not need that. He does not recall burning several pots on his stove recently, and that this could pose a safety risk to others. Collateral information from other organizations suggests the patient was not reliable with home support and care, and also refused care at times.

Although the patient seems to provides a reasonable estimate of income, expenses, and cost of living, the patient lacks the ability to problem solve for more realistic and reasonable solutions. The patient has poor insight and marked executive dysfunction due to [diagnosis].

Based on my assessment today and the collateral available to me, the patient does not have capacity to manage finances and does not have capacity to make decision around LTC placement. The patient's care needs would be best supported in a structured setting like an assisted care or long term care facility.

The patient is not capable to give/refuse consent to a care facility admission at this time based on the above information [and serial assessments, collateral from others, etc.].

1) Silberfeld, M., & Fish, A. (1994). When the mind fails: A guide to dealing with incompetency. University of Toronto Press.