A regional long-term care home in central Alberta admitted an 81-year-old woman following a series of strokes that left her with significant cognitive impairment and limited mobility on her left side. The admission occurred 14 months ago, and the resident initially settled into the facility without significant difficulty. Her daughter, who lives in a neighbouring city approximately 90 kilometres away, signed the admission paperwork and has remained the primary family contact throughout the placement. No personal directive was located among the resident's belongings at admission, and the intake documentation notes only that the daughter "will make decisions" without specifying under what legal authority she would do so.

Over the past 3 months, the resident's cognitive state has fluctuated considerably. On some days she engages in coherent conversation with staff, expresses clear preferences about her meals and daily routine, and demonstrates awareness of her surroundings. On other days she does not recognize familiar caregivers, becomes agitated when approached for routine care, and has on 2 occasions physically resisted assistance with bathing. The care team has not conducted a formal capacity assessment at any point since admission, relying instead on informal observations documented inconsistently across nursing notes.

The immediate question arose when the resident developed a persistent skin ulcer on her lower left leg. The attending physician recommended a debridement procedure to prevent further tissue damage and potential infection. When a nurse approached the resident to explain the procedure and obtain consent, the resident stated clearly that she did not want "anyone cutting on her" and asked to be left alone. The nurse documented this refusal in the progress notes but did not record any assessment of whether the resident understood the nature of the proposed treatment, its risks, or the consequences of refusing it.

The daughter, when contacted by telephone the following day, expressed frustration that staff had not simply proceeded with the treatment. She insisted that her mother "doesn't know what she's saying half the time" and directed the care home to perform the debridement. The facility administrator, uncertain how to proceed, instructed staff to delay the procedure pending further review. The wound has since worsened, and the physician has now documented that the ulcer presents a risk of serious infection if left untreated for more than 7 to 10 additional days.

The care home's existing consent documentation for this resident consists of a single general consent form signed at admission, which authorizes "routine nursing care and medical treatment as required." The form does not address capacity, does not identify a substitute decision-maker by legal designation, and does not reference any personal directive or guardianship order. No capacity assessment, formal or informal, appears anywhere in the resident's chart.