The VA Office of Inspector General conducted an inspection in response to allegations that a patient’s rights were violated; that the patient’s Durable Power of Attorney for Health Care (DPAHC) may not have been valid; and that facility leaders were not responsive to staff and family concerns about this case. We did not substantiate that a patient with dementia, who was deemed to have decision making capacity regarding where he wanted to live, was held against his will for an extended period of time. The Interdisciplinary Treatment Team made efforts to address the complicated medical, ethical, and legal considerations that delayed the patient’s discharge to a Florida assisted care facility. We could neither confirm nor refute the validity of the patient’s DPAHC. Due to a lack of medical record documentation, a Regional Counsel attorney was unable to determine whether the document was legally executed. However, during most of the patient’s nearly 3-year stay at the facility, the son was the patient’s recognized health care agent by both facility staff and other family members. We confirmed that facility leaders did not appear to respond to clinicians’ requests for assistance. We discussed these issues with facility leadership and were assured that complicated cases will continue to be discussed at the daily executive clinical meeting. We made no recommendations.