Long-Term Care Capacity Assessment

In Ontario, the law requires the consent of a patient before admission to a care facility such as a long-term care (LTC) home. However, one may not recognize his or her need for placement into a long-term care home, even when this placement is important to their health. Cognitive impairment or dementia, may cause a decline in memory, reasoning, planning and judgement, and make one incapable to decide if they need LTC. Thus, if incapacity is suspected, the patient’s capacity for consent for LTC needs to be assessed.

Sample Documentation for Capacity Assessment

Over course of assessments from [DATE(S)], patient is [CAPABLE/INCAPABLE] to make an admission decision.

Patient has [MMSE/MOCA scores], and [HAS/DOES NOT HAVE] insight into their cognitive limitations. Due to [DIAGNOSIS], patient is [ABLE/UNABLE] to understand information presented to them. Patient currently [HAS/DOES NOT HAVE] the ability to retain information and convey this back to demonstrate that they have understood.

When discussing the topics of staying at home versus moving to a long term care facility, patient is [ABLE/UNABLE] to answer questions regarding consequences of staying at home versus going to long term care. When the patient was asked about what problems they are currently having, pt [DENIED/ADMITTED] to all concerns. Specifically questioned about insight into cognitive abilities, replied [“ ”] on repeated occasions.

It is evident that the patient [DOES/DOES NOT] understand the extent of their cognitive deficits, and/or how these deficits are affecting their safety. When asked about admission to a nursing home to help with any problems, Patient [WAS/WAS NOT] able to discuss this rationally. It is evident that patient is [ABLE/UNABLE] to appreciate any consequences of living independently versus in a nursing home. Regarding other ways to look after one's condition, patient [DOES/DOES NOT] feel that the cognitive problems interfere with function. When questioned regarding what would happen if patient indeed chose to move into a nursing home, they responded [“ ”].

Patient is deemed [CAPABLE/INCAPABLE] to make decisions regarding admission to long term care. [IF INCAPABLE: The appropriate forms were completed, and the patient was given the rights information sheet. This sheet was explained in detail, should the patient wish to appeal this finding. Patient [DID/DID NOT] indicate an intent to appeal this.]

Any time one suspects elder abuse in a retirement home or long-term care home, one must call to report to the Ministry