5 Things an RCFE Administrator Should Know About Surrogate Decision Making

In Residential Care Facilities for the Elderly (RCFEs), decision-making authority is not always as clear-cut as one might hope. When a resident loses the ability to make informed decisions due to dementia, stroke, or another debilitating condition, someone must step in to make choices on their behalf. 

This is where a surrogate decision maker becomes essential.

Whether you’re new to the role or a seasoned RCFE professional, understanding how surrogate decision making functions is critical. 

At Assisted Living Education, we’ve trained thousands of administrators through our RCFE administrator training, and one recurring area of confusion revolves around the surrogate decision maker’s authority, limitations, and responsibilities.

Here are five essential things every RCFE administrator needs to know about working with surrogate decision makers.

1. What Is a Surrogate Decision Maker?

A surrogate decision maker, when it comes to healthcare and the care of others, is someone legally authorized to make decisions for another person who is no longer able to make those decisions themselves. These decisions often involve medical care, living arrangements, and personal wellbeing.

Surrogates are typically appointed based on a preexisting relationship, such as a spouse, adult child, or close friend, especially when no formal legal designation like a durable power of attorney (POA) exists. The exact process for appointing a surrogate may vary by state, but in California, the Health Care Decisions Law outlines who may serve in this role in the absence of an advance health care directive.

In the context of senior living, the RCFE surrogate decision maker becomes the voice of the resident. Administrators need to understand who that person is, how their authority was established, and what scope of decisions they are permitted to make. 

In this scenario,  the resident should have  previously obtained an Advance Health Care Directive (AHCD) or a Living Will that documents their wishes. California also has a Physician’s Order for Life-Sustaining Treatment (POLST) form that can be part of your admission packet if the resident has not completed an AHCD. The resident’s physician signs this form that details the type of care to be administered in an emergency and a decision maker is identified.

It’s important to have the proper documentation in place. In addition, the resident must be deemed incapable of making health-related decisions on their own before a surrogate can take over that role.  

Becoming a surrogate decision maker for a senior loved one can help ease decision-making in a time of need.

2. What Is the Difference Between a Surrogate Decision Maker and a Power of Attorney?

This is a question we hear often in our RCFE administrator training. While the terms can seem interchangeable, they are not the same.

• A power of attorney (POA) is a legal document in which an individual (the principal) designates another person (the agent) to make decisions on their behalf. This can include financial and legal matters.
• A healthcare proxy—sometimes used interchangeably with medical Advance Health Care Directive —is a form of POA specifically for healthcare decisions.
• A surrogate decision maker, on the other hand, is generally appointed when no POA exists and a person becomes incapacitated. Their role is often established through medical necessity and recognized by healthcare providers, not a legal document.

Understanding this difference ensures administrators know whom to turn to and under what circumstances. “Elder care advocate” is one term all RCFE administrators should know, as these advocates often work alongside or as surrogate decision makers.

3. What Are Examples of Surrogate Decision Maker Responsibilities?

The responsibilities of a surrogate decision maker are both broad and sensitive, often carrying significant emotional weight. Their core duty is to make choices aligned with the resident’s previously expressed wishes, values, and best interests.

Some common surrogate decision maker responsibilities include:

• Approving or declining medical treatments (e.g., surgeries, medications)
• Making end-of-life decisions, such as DNR (Do Not Resuscitate) orders
• Choosing or changing care facilities
• Consenting to psychiatric care or treatments
• Communicating with healthcare providers and RCFE staff

As an RCFE administrator, you must know how to verify that the surrogate has the legal right to act and understand the limits of their decision-making. For example, they may not have authority over financial matters unless separately designated under a financial POA.

Every suorrogate decision maker needs to have necessary state-certified paperwork completed to begin the decision-making process.

4. Surrogate Decision Making Must Be Documented and Respected

Every decision made by a surrogate must be recorded in the resident’s file, including:

• The surrogate’s full name and relationship to the resident
• The reason for the resident’s incapacity
• Evidence of the surrogate’s legal standing (if available)
• A log of decisions made on the resident’s behalf

Administrators must also ensure that staff are aware of who the surrogate is and are trained to communicate appropriately. Misunderstandings can lead to delays in care or legal complications.

The CDSS has a Provider Information Notice (PIN) 25-04-ASC that clarifies the different POA’s (Power of Attorney), responsibilites and exceptions in decision making.  You’ll also find a helpful chart for quick reference here.

Case Example: Navigating a Surrogate’s Role in Real Time

Consider the case of Mrs. Thompson, an 84-year-old RCFE resident with mid-stage Alzheimer’s. She had no advanced directive and no family nearby, but a close friend, Janice, had accompanied her to most doctor appointments over the years. When Mrs. Thompson was hospitalized and unable to consent to treatment, the attending physician designated Janice as the surrogate decision maker under California’s default surrogate hierarchy.

Upon Mrs. Thompson’s return to the RCFE, the administrator ensured that Janice’s status was documented, shared with staff, and used to guide care decisions. This clear chain of authority prevented confusion during a later emergency, when a decision regarding hospitalization had to be made quickly.

This real-world example demonstrates how clarity and documentation in surrogate decision making can prevent delays and distress in urgent care scenarios.

5. RCFE Administrators Play a Key Role in Supporting Surrogates

While RCFE administrators are not surrogate decision makers themselves, they do play a crucial role in facilitating the decision-making process.

Some best practices include:

• Initiating conversations early with residents and families about advance directives and POAs
• Providing educational materials about surrogate roles and responsibilities
• Serving as a liaison between surrogates and healthcare providers
• Monitoring for potential abuse or misuse of surrogate authority
• Working with the physician to determine if the resident is truly incapacitated to make decisions

It’s also essential to recognize that not all surrogate decisions will align with what the RCFE staff believes is best. Administrators should approach these situations with diplomacy, professionalism, and, when necessary, the involvement of legal counsel or Adult Protective Services.

Supporting surrogates emotionally is also part of the job. Many find the role overwhelming, particularly when facing end-of-life decisions. Helping them understand they are not alone and that the RCFE is a partner in care can make all the difference.

Final Thoughts: The Surrogate Decision Maker in the Larger RCFE Landscape

RCFE administrators should regularly revisit their facility’s policies on surrogate decision making. Ensure that staff are trained, records are complete, and residents’ rights are protected.

Families often ask, “Who will speak for my loved one if they no longer can?” The answer lies in part with the RCFE’s diligence in understanding, supporting, and collaborating with surrogate decision makers.

By mastering these five key areas, administrators can ensure their facilities meet the standards that elderly care decision makers look for in an RCFE. In doing so, they not only protect residents, but also build trust with families and elevate the quality of care their community provides.

Assisted Living Education is a leader in RCFE certification and administrator training in California. Our mission is to empower administrators with the knowledge and tools they need to thrive in the senior care industry. For more resources or to learn about our courses, visit us at assistedlivingeducation.com or read more about Important Things To Look for in an RCFE Administrator Program.