Court Opinion

ID: 7803490
Source: CourtListenerOpinion
Date Created: 2022-08-25 15:01:47.42648+00
Date Added: 2024-06-11T16:29:40.197938
License: Public Domain

The summaries of the Colorado Court of Appeals published opinions
  constitute no part of the opinion of the division but have been prepared by
  the division for the convenience of the reader. The summaries may not be
    cited or relied upon as they are not the official language of the division.
  Any discrepancy between the language in the summary and in the opinion
           should be resolved in favor of the language in the opinion.

                                                                 SUMMARY
                                                             August 25, 2019

                                2022COA96

No. 21CA0118, Fresquez v. Trinidad Inn — Health and Welfare
— Health Care Availability Act — Arbitration Agreements; ADR
— Arbitration; Agency — Actual Authority — Apparent
Authority

     A division of the court of appeals considers an agent’s

authority to bind a principal to an arbitration agreement under the

Health-Care Availability Act (the Act), §§ 13-64-101 to -503, C.R.S.

2021. While the Act details the steps a health care provider must

take to form an enforceable arbitration agreement with a patient, it

is silent regarding the requirements that a patient’s agent must

satisfy to bind the patient to an arbitration agreement. In this case,

the division considers the novel issue of whether an agent with

actual authority to execute the documents required to admit the

patient to a health care facility necessarily also possesses the
authority to bind the patient to an arbitration agreement with the

facility.

      The division holds that an agent’s actual authority to make

health care decisions for a patient and to sign the documents

necessary to admit the patient to a health care facility does not

encompass the authority to bind the patient to an arbitration

agreement, unless the patient has granted the agent an unlimited

power of attorney or otherwise clearly granted the agent the specific

authority to bind the patient to an arbitration agreement.
COLORADO COURT OF APPEALS                                         2022COA96

Court of Appeals No. 21CA0118
Las Animas County District Court No. 20CV30010
Honorable J. Clay McKisson, Judge

Ralph R. Fresquez, individually and as Personal Representative of the Estate of
Beatrice Trujillo, deceased,

Plaintiff-Appellee,

v.

Trinidad Inn, Inc., d/b/a Trinidad Inn; C&G Health Care Management, Inc.;
and Brittnee Fransua, in her Capacity as Administrator of Trinidad Inn,

Defendants-Appellants.

                      JUDGMENT AFFIRMED AND CASE
                       REMANDED WITH DIRECTIONS

                                  Division VII
                          Opinion by JUDGE LIPINSKY
                         Navarro and Kuhn, JJ., concur

                          Announced August 25, 2022

Reddick Law, PLLC, Brian D. Reddick, Robert W. Francis, Little Rock,
Arkansas, for Plaintiff-Appellee

Messner Reeves LLP, Douglas C. Wolanske, Kendra N. Beckwith, Mary Byrne
Fletcher, Darren D. Alberti, Denver, Colorado, for Defendants-Appellants
¶1     The Health-Care Availability Act (the Act), §§ 13-64-101

 to -503, C.R.S. 2021, permits health care providers to ask their

 patients to sign arbitration agreements. The General Assembly

 adopted the Act based on its belief that increasing the number of

 medical malpractice cases resolved through arbitration, rather than

 through the judicial system, would help “assure the continued

 availability of adequate health-care services . . . by containing the

 significantly increasing costs of malpractice insurance for medical

 care institutions.” § 13-64-102(1), C.R.S. 2021.

¶2     But patients cannot be compelled to surrender their right to

 sue health care providers in a court of law. The Act specifies that,

 although a health care provider may ask a patient to sign an

 arbitration agreement, the patient may not be denied care if the

 patient refuses to sign the agreement or timely exercises the

 statutory right to rescind an arbitration agreement the patient

 previously signed. Thus, a patient must be admitted to a hospital,

 skilled nursing facility, or other health care facility even though the

 patient declined to consent to arbitrate future disputes involving the

 facility.

                                    1
¶3     Significantly, although the Act details the steps a health care

 provider must take to form an enforceable arbitration agreement

 with a patient, it is silent regarding the requirements that a

 patient’s agent must satisfy to bind the patient to an arbitration

 agreement. In this case, we consider the novel issue of whether an

 agent with actual authority to execute the documents required to

 admit a patient to a health care facility necessarily also possesses

 the authority to bind the patient to an arbitration agreement with

 the facility.

¶4     We hold that when an agent has authority to execute the

 documents necessary for admission of a patient to a health care

 facility, such authority does not, without more, encompass the

 authority to bind the patient to an arbitration agreement where the

 patient was unaware the facility would ask the agent to sign an

 arbitration agreement and the patient never discussed arbitration

 with the agent or with representatives of the facility.

¶5     In his lawsuit against defendants, Trinidad Inn, Inc., a skilled

 nursing facility; C&G Health Care Management, Inc., which owns,

 operates, and manages Trinidad Inn; and Brittnee Fransua, in her

 capacity as administrator of Trinidad Inn (collectively, the Trinidad

                                    2
 defendants), plaintiff, Ralph R. Fresquez, alleged that their

 negligence caused the death of Fresquez’s mother, Beatrice Trujillo,

 while she was a resident at Trinidad Inn. The Trinidad defendants

 moved to compel arbitration based on an arbitration agreement that

 Fresquez signed, purportedly in his capacity as Trujillo’s agent, at

 the time of Trujillo’s admission to Trinidad Inn. Following an

 evidentiary hearing, the district court denied the Trinidad

 defendants’ motion on the grounds that the arbitration agreement

 was invalid.

¶6    The Trinidad defendants appeal the district court’s order

 denying their motion to compel arbitration. We affirm.

                           I.   Background

¶7    Trujillo decided to move into Trinidad Inn after finding it

 difficult to live alone. Fresquez assisted Trujillo with her admission

 to Trinidad Inn. As part of this process, he provided the social

 services assistant at Trinidad Inn with a referral packet from

 Trujillo’s primary care physician. The referral packet included a

 note from the physician saying that “attorney is requesting nursing

 home placement” for Trujillo. The social services assistant said she

                                   3
 believed the reference to “attorney” meant that Trujillo had executed

 a power of attorney authorizing Fresquez to act on her behalf.

¶8    Fresquez coordinated Trujillo’s admission to Trinidad Inn with

 the social services assistant. The social services assistant testified

 that, at the time of Trujillo’s admission, Fresquez told her that he

 held a power of attorney for Trujillo. The social services assistant

 never saw any such power of attorney, however.

¶9    Fresquez recalled that, shortly after he and Trujillo arrived at

 Trinidad Inn for Trujillo’s admission, the social services assistant

 called him to her office “to sign . . . papers.” One of those papers

 was a “Voluntary Agreement for Arbitration” (the arbitration

 agreement). The arbitration agreement stated that “[t]he parties

 agree that they shall submit to binding arbitration all disputes

 against each other.” It defined the parties as “Trinidad Inn,

 including its Owners, Managers, Employees, and Agents,” and “the

 Resident.” The arbitration agreement defined “the Resident” as

 Trujillo and her “family, estate, heirs, personal representatives, or

 . . . any person claiming that a duty of care arises from [Trujillo’s]

 stay and care at [Trinidad Inn].”

                                     4
¶ 10     Fresquez later said that he signed the arbitration agreement,

  together with the other documents the social services assistant

  provided to him, because he believed that Trinidad Inn would not

  admit Trujillo if he did not sign it. No representative of Trinidad Inn

  discussed the arbitration agreement or the other documents with

  Trujillo. Trujillo died six months after her admission to Trinidad

  Inn.

¶ 11     In denying the Trinidad defendants’ motion to compel

  arbitration, the district court ruled that (1) Fresquez possessed

  actual authority to bind Trujillo to the arbitration agreement; (2) the

  “rule of equal dignities” invalidated such authority, however,

  because no document memorialized Fresquez’s authority; and

  (3) Fresquez lacked apparent authority to bind Trujillo to the

  arbitration agreement.

                               II.   Analysis

¶ 12     The Trinidad defendants contend that the district court erred

  by ruling that the arbitration agreement was invalid. They

  specifically argue that Trujillo granted Fresquez actual authority to

  bind her to the arbitration agreement and that the equal dignities

  rule does not apply here, even though no writing memorialized

                                     5
  Fresquez’s authority to act on behalf of Trujillo at the time of

  Trujillo’s admission to Trinidad Inn. In the alternative, they

  contend that Fresquez possessed apparent authority to bind Trujillo

  to the arbitration agreement.

                         A.   Standard of Review

¶ 13   “We review de novo the district court’s decision on a motion to

  compel arbitration.” Lujan v. Life Care Ctrs. of Am., 222 P.3d 970,

  972 (Colo. App. 2009). “In considering a motion to compel

  arbitration, the district court must first determine whether a valid

  agreement to arbitrate exists between the parties to the action.” Id.

  “The court may properly refuse to compel arbitration only when

  there is no valid agreement to arbitrate or when the issue sought to

  be arbitrated is clearly beyond the scope of the arbitration

  provision.” Id. “Whether a valid agreement to arbitrate exists is a

  matter of law that we review de novo.” Id.

¶ 14   In this case, the validity of the arbitration agreement hinges on

  the existence and scope of any agency relationship between Trujillo

  and Fresquez and, specifically, whether Fresquez possessed the

  authority to bind Trujillo to the arbitration agreement. “Whether an

  agency relationship exists generally is a question of fact, though the

                                     6
  court may decide the question as one of law when the facts are

  undisputed.” Villalpando v. Denver Health & Hosp. Auth., 181 P.3d

  357, 363 (Colo. App. 2007); see also Gross v. GGNSC Southaven,

  L.L.C., 817 F.3d 169, 180 (5th Cir. 2016) (holding that the scope of

  a son’s actual authority to bind his mother to a nursing home’s

  arbitration agreement was “a question of fact”); Rush Creek Sols.,

  Inc. v. Ute Mountain Ute Tribe, 107 P.3d 402, 406 (Colo. App. 2004)

  (“The issue of apparent authority is generally an issue of fact to be

  determined by the trial court. . . . However, if the underlying facts

  are undisputed, fact finding is not required, and the legal effect of

  those facts constitutes a question of law.”).

¶ 15   “On appeal, we review the trial court’s factual findings under a

  clear error standard.” Villalpando, 181 P.3d at 363. We “won’t

  disturb such findings if there is any evidence in the record

  supporting them.” Woodbridge Condo. Ass’n v. Lo Viento Blanco,

  LLC, 2020 COA 34, ¶ 24, 490 P.3d 598, 606, aff’d, 2021 CO 56,

  489 P.3d 735.

                                     7
                            B.   Applicable Law

               1.    Arbitration Agreements Under the Act

¶ 16   As a general rule, Colorado favors arbitration agreements. See

  J.A. Walker Co. v. Cambria Corp., 159 P.3d 126, 128 (Colo. 2007).

  But health care arbitration agreements, unlike other types of

  arbitration agreements, are subject to strict requirements set forth

  in the Act. See § 13-64-403, C.R.S. 2021. Although “the [Act]

  allows arbitration of disputes, [it] also contains protective provisions

  curbing abusive practices in obtaining agreements to arbitrate.”

  Moffett v. Life Care Ctrs. of Am., 219 P.3d 1068, 1073 (Colo. 2009).

¶ 17   The Act provides that arbitration agreements must be

  voluntary. § 13-64-403(1) (“It is the intent of the general assembly

  that an arbitration agreement be a voluntary agreement between a

  patient and a health-care provider . . . .”). It specifies that “[n]o

  health-care provider shall refuse to provide medical care services to

  any patient solely because such patient refused to sign [an

  arbitration agreement] or exercised the ninety-day right of

  rescission.” § 13-64-403(7). Health care providers must include

  this statutory language, among other required disclosures, in any

  agreement with a patient containing an arbitration provision.

                                      8
  § 13-64-403(4). The statement must appear “[i]mmediately

  preceding the signature lines for such an agreement . . . printed in

  at least ten-point, bold-faced type.” Id. A health care provider’s

  failure to comply with these statutory requirements renders a

  health care arbitration agreement unenforceable. Johnson v.

  Rowan Inc., 2021 COA 7, ¶ 24, 488 P.3d 1174, 1179.

                          2.   Actual Authority

¶ 18   “[A]n agent acts with actual authority when, at the time of

  taking action that has legal consequences for the principal, the

  agent reasonably believes, in accordance with the principal’s

  manifestations to the agent, that the principal wishes the agent so

  to act.” State Farm Mut. Auto. Ins. Co. v. Johnson, 2017 CO 68,

  ¶ 21, 396 P.3d 651, 656 (quoting Restatement (Third) of Agency

  § 2.01 (Am. L. Inst. 2006)). Actual authority is premised on “a

  principal’s expressive conduct toward an agent, through which the

  principal manifests assent to be affected by the agent’s action, and

  the agent’s reasonable understanding of the principal’s

  manifestation.” Restatement (Third) of Agency § 2.01 cmt. c.

¶ 19   “The focal point for determining whether an agent acted with

  actual authority is the agent’s reasonable understanding at the time

                                    9
  the agent takes action.” Id. “An agent has actual authority to take

  action designated or implied in the principal’s manifestations to the

  agent and acts necessary or incidental to achieving the principal’s

  objectives, as the agent reasonably understands the principal’s

  manifestations and objectives when the agent determines how to

  act.” Id. § 2.02(1). “The context in which principal and agent

  interact, including the nature of the principal’s . . . personal

  situation, frames the reasonableness of an agent’s understanding of

  the principal’s objectives.” Id. § 2.02 cmt. e. “An agent’s actual

  authority encompasses acts necessary to accomplish the end the

  principal has directed that the agent achieve.” Id.

¶ 20   The inquiry into whether an agent possessed the actual

  authority to execute a document on behalf of the principal “contains

  both an objective and a subjective component: the agent must

  subjectively hold the belief that [he] possesses authority, and that

  belief must be objectively reasonable in light of the principal’s

  actions.” Stein Eriksen Lodge Owners Ass’n v. MX Techs. Inc., 2022

  UT App 30, ¶ 26, 508 P.3d 138, 147 (citing Restatement (Third) of

  Agency § 2.02 cmt. e).

                                     10
¶ 21   Actual authority incorporates concepts of express and

  implied authority. State Farm, ¶ 21, 396 P.3d at 656. “Express

  authority exists when the principal directly states that the agent

  may perform a particular act on the principal’s behalf.” Id. In

  contrast, implied authority includes “the authority to perform acts

  that are ‘incidental to, or are necessary, usual, and proper to

  accomplish or perform, the main authority expressly delegated to

  the agent.’” Id. at ¶ 22, 396 P.3d at 656 (quoting Willey v. Mayer,

  876 P.2d 1260, 1264 (Colo. 1994)); see Restatement (Third) of

  Agency § 2.01 cmt. b (stating that implied authority is “actual

  authority either (1) to do what is necessary, usual, and proper to

  accomplish or perform an agent’s express responsibilities or (2) to

  act in a manner in which an agent believes the principal wishes the

  agent to act based on the agent’s reasonable interpretation of the

  principal’s manifestation in light of the principal’s objectives and

  other facts known to the agent”). “Implied authority is actual

  authority circumstantially proved.” Citywide Banks v. Armijo, 313

  P.3d 647, 652 (Colo. App. 2011).

¶ 22   In Moffett, the supreme court held that a patient’s attorney-in-

  fact possesses the authority to bind the patient to an arbitration

                                     11
  agreement under the Act where the governing power of attorney

  does not limit the agent’s authority “to waive the right to a jury trial

  and submit to arbitration” on behalf of the patient. 219 P.3d at

  1076. The supreme court concluded in Moffett that the patient’s

  attorney-in-fact was authorized to bind the patient to an arbitration

  agreement “[a]bsent a restriction or limitation on his authority

  under the [power of attorney] he holds.” Id. at 1079. “The [Act] and

  Colorado’s recognized policy favoring arbitration coexist with well-

  established statutory and common law doctrines governing agency

  and [powers of attorney].” Id. at 1074.

¶ 23   For purposes of section 13-64-403, the section of the Act

  addressing arbitration agreements, “the term ‘patient’ . . . includes

  a person acting with legal authority under a [power of attorney] to

  enter into such an agreement on behalf of [an] incapacitated

  patient.” Id. The authority of the person acting on behalf of the

  patient can arise from a source other than a power of attorney. See

  id. at 1078 (“[S]ection 13-64-403 cannot be read without regard for

  the extensive statutory and common law doctrine permitting

  authorized agents to bind principals in all kinds of contracts,

  including arbitration agreements.”); Lujan, 222 P.3d at 977 (holding

                                     12
  that a determination of an agent’s scope of authority under a

  medical durable power of attorney must include an analysis of the

  “common law agency principles or applicable statutory powers of

  attorney”) (emphasis omitted).

¶ 24   Moffett teaches that courts must carefully scrutinize the scope

  of an agent’s actual authority to determine whether the agent was

  empowered to bind a patient to a health care arbitration agreement.

  The reasoning of Moffett, therefore, is not limited to cases in which

  the principal executed a power of attorney. For this reason, courts

  must apply the law of agency, subject to the restrictions imposed

  under the Act, to determine whether a patient’s agent is authorized

  to waive the patient’s right to seek damages in a court of law.

                        3.    Apparent Authority

¶ 25   In contrast to actual authority, “[a]pparent authority is the

  power held by an agent or other actor to affect a principal’s legal

  relations with third parties when a third party reasonably believes

  the actor has authority to act on behalf of the principal and that

  belief is traceable to the principal’s manifestations.” Restatement

  (Third) of Agency § 2.03 (emphasis added). “Apparent authority . . .

  ‘flows only from the acts and conduct of the principal.’” State Farm,

                                    13
  ¶ 20, 396 P.3d at 656 (quoting Zions First Nat’l Bank v. Clark Clinic

  Corp., 762 P.2d 1090, 1095 (Utah 1988)). It is “established by proof

  of ‘written or spoken words or other conduct of the principal which,

  reasonably interpreted, causes a person to believe that the principal

  consents to have the act done on his behalf by a person purporting

  to act for him.’” Villalpando, 181 P.3d at 363 (quoting Lucero v.

  Goldberger, 804 P.2d 206, 209 (Colo. App. 1990)).

       C.     Fresquez Lacked Actual Authority to Bind Trujillo to
                          the Arbitration Agreement

¶ 26   We now turn to the nature of the authority that Trujillo

  granted to Fresquez and whether, under that authority, Fresquez

  could bind Trujillo to the arbitration agreement. This analysis

  requires us to determine the type of authority that Trujillo provided

  to Fresquez and the scope of that authority. The parties agree, and

  the record reflects, that Trujillo never executed a power of attorney

  appointing Fresquez as her agent before Fresquez signed the

  arbitration agreement.

       1.     The District Court Did Not Clearly Err by Finding that
            Fresquez Possessed Actual Authority to Make Health Care

                                    14
       Decisions and Execute Documents Necessary to Admit Trujillo
                             to Trinidad Inn

¶ 27   Based on undisputed evidence presented at the hearing, the

  district court found that

           Trujillo wanted Fresquez to make decisions regarding her

            medical care and her admission to Trinidad Inn;

           Fresquez possessed actual authority to “make admission

            decisions and sign documents for the purpose of having

            [Trujillo] admitted to Trinidad Inn”;

           before Trujillo’s admission, Trujillo manifested her assent

            for Fresquez to sign such documents;

           Fresquez “signed the admission documents so that

            [Trujillo] could be admitted” to Trinidad Inn;

           Fresquez “reasonably believed that he was carrying out

            [Trujillo’s] wishes when he signed the admission

            documents”; and

           “Trujillo’s actions and statements after her admission

            corroborate [Fresquez’s] testimony that he was

            authorized to make admission decisions and sign

                                   15
             documents for the purpose of having her admitted to

             Trinidad Inn.”

¶ 28    The evidence confirms that Trujillo wanted Fresquez to act as

  her agent in making medical care decisions on her behalf, including

  the decisions necessary for her admission to Trinidad Inn. We thus

  conclude that the district court did not clearly err by finding that

  Fresquez possessed actual authority to make medical care decisions

  for Trujillo and to execute the admission documents on her behalf.

       2.   The District Court Erred by Determining that Fresquez
              Possessed Actual Authority to Bind Trujillo to the
                            Arbitration Agreement

¶ 29    The district court’s characterization of Fresquez’s actual

  authority did not stop with its finding that Trujillo authorized

  Fresquez to make medical care decisions for her and to execute

  Trinidad Inn’s admission documents on her behalf. The district

  court also said that, by signing the arbitration agreement, Fresquez

  was “making an admission decision for . . . Trujillo” and “the

  [arbitration agreement] was within the scope of documents that

  [Trujillo] gave [Fresquez] authority to sign.”

¶ 30    These statements can be read in one of two ways. They can be

  read as further findings of fact. Alternatively, they can be

                                     16
  interpreted as a legal conclusion that, under the Act, Fresquez’s

  actual authority “to make admission decisions and sign documents

  for the purpose of having her admitted to Trinidad Inn” necessarily

  meant he possessed the authority to bind Trujillo to the arbitration

  agreement.

¶ 31    If the district court’s statements are findings of fact based on

  evidence presented at the hearing, we review them for clear error.

  See Villalpando, 181 P.3d at 363. If they are a legal determination,

  we review de novo whether, under the Act, Fresquez’s authority to

  “make admission decisions” and sign admission documents for

  Trujillo necessarily encompassed the authority to bind Trujillo to

  the arbitration agreement. See Johnson, ¶ 16, 488 P.3d at 1178.

       a.     If the District Court’s Statements Regarding Fresquez’s
            Authority to Bind Trujillo to the Arbitration Agreement Were
                   Findings of Fact, They Were Clearly Erroneous

¶ 32    The record does not establish that, based on Trujillo’s

  “expressive conduct,” Fresquez reasonably understood that Trujillo

  wished for him to waive her right to seek a legal remedy through the

  judicial system. See Restatement (Third) of Agency § 2.01 cmt. c

  (explaining that determining whether the agent is authorized to

  perform certain acts requires both the “principal’s expressive

                                      17
  conduct” and the agent’s “reasonable understanding” of the

  principal’s wishes manifested through that conduct).

¶ 33   The district court did not find, and the record does not show,

  that Trujillo and Fresquez ever discussed the arbitration agreement

  specifically or the concept of arbitration generally. The record

  contains no evidence that any of Trujillo’s words or conduct related

  in any way to arbitration. Therefore, the district court had no

  evidentiary basis to support a finding of fact that Fresquez

  reasonably understood that Trujillo had granted him actual

  authority to bind her to the arbitration agreement.

¶ 34   The Trinidad defendants argue that, because Fresquez made

  certain financial and administrative decisions on Trujillo’s behalf,

  his actual authority necessarily extended to binding Trujillo to the

  arbitration agreement. But the record shows that those financial

  and administrative decisions related exclusively to Trujillo’s

  admission to and residency at Trinidad Inn. Such decisions were

  thus “incidental to, or [were] necessary, usual, and proper to

  accomplish or perform, the main authority expressly delegated to

  the agent.” State Farm, ¶ 22, 396 P.3d at 656 (quoting Willey, 876

  P.2d at 1264); see Restatement (Third) of Agency § 2.01 cmt. b.

                                    18
¶ 35   For the same reasons, to the extent the district court found

  that Fresquez reasonably believed he possessed the authority to

  bind Trujillo to the arbitration agreement simply because he was

  authorized to make health care decisions for her and to sign the

  admission documents, such finding was also clearly erroneous.

  The arbitration agreement expressly stated, consistent with the Act,

  that Trinidad Inn could not “refuse to provide medical care services”

  to a patient who declined to sign it. For this reason, the arbitration

  agreement cannot be reasonably understood to be an “admission

  document.” Thus, nothing in the record indicated that Fresquez

  could have reasonably believed, through Trujillo’s expressed wish

  that he make health care decisions for her and sign the admission

  documents, that he possessed actual authority to bind Trujillo to

  the arbitration agreement. Rather, the record shows that, as

  Trujillo was being admitted to Trinidad Inn, the social services

  assistant handed Fresquez documents and he signed them.

¶ 36   Based on the district court’s findings of fact, supported by the

  evidence, that Fresquez’s actual authority included making medical

  care decisions for Trujillo and executing the documents necessary

  for Trujillo’s admission to Trinidad Inn, we next turn to the legal

                                    19
  question of whether, under the Act, such authority necessarily

  encompassed the authority to bind Trujillo to the arbitration

  agreement.

       b.   If the District Court’s Statements Regarding Fresquez’s
         Authority to Bind Trujillo to the Arbitration Agreement Were a
                   Legal Determination, They Were Erroneous

¶ 37    “An agent has a duty to take action only within the scope of

  the agent’s actual authority.” Restatement (Third) of Agency § 8.09.

  In other words, “[i]n the context of the agent’s relationship with the

  principal, the boundary of an agent’s rightful action is the scope of

  the agent’s actual authority.” Id. § 8.09 cmt. b. “An agent’s actual

  authority encompasses acts necessary to accomplish the end the

  principal has directed that the agent achieve.” Id. § 2.02 cmt. e; see

  also State Farm, ¶ 22, 396 P.3d at 656.

¶ 38    Here, the “end” that Trujillo directed Fresquez to achieve was

  her admission to Trinidad Inn so she could receive medical care at

  that facility. The district court found that “Trujillo’s actions and

  statements after her admission corroborate [Fresquez’s] testimony

  that he was authorized to make admission decisions and sign

  documents for the purpose of having her admitted to Trinidad Inn.”

  (Emphasis added.)

                                    20
¶ 39   In making its determination that Fresquez’s actual authority

  regarding health care and admission decisions included the

  authority to bind Trujillo to the arbitration agreement, the district

  court distinguished Lujan on four grounds: (1) this case does not

  involve a health care proxy, and Trujillo was neither incapacitated

  nor mentally incompetent at the time of her admission to Trinidad

  Inn; (2) Trujillo chose her decision-maker and relied on him for that

  purpose; (3) Trujillo “determined that [Fresquez] had authority to

  make decisions on her behalf that included decisions related to her

  admission at Trinidad Inn”; and (4) this case involves evidence of “a

  formal understanding” between Fresquez and Trujillo regarding the

  existence and scope of Fresquez’s authority. We disagree that the

  reasoning of Lujan is inapposite here.

¶ 40   We acknowledge that, in Lujan, a division of this court

  considered whether a designated health care proxy is empowered to

  bind an incapacitated patient to an arbitration agreement. 222

  P.3d at 971. But, despite the narrowness of the issue presented in

  Lujan, the division’s discussion of the distinction between the

  documents required to admit a patient to a skilled nursing facility

  and an arbitration agreement is pivotal to our analysis. Id. at 973-

                                    21
  74. Particularly relevant here, the division contrasted a health care

  proxy’s statutorily prescribed authority with the more expansive

  authority that a principal-agent relationship can create. Id. at 973.

¶ 41   “[A] health care proxy is distinct from an attorney-in-fact

  acting under a power of attorney.” Id. at 977. The division

  reasoned that “the statutory authority afforded a health care proxy

  should be construed narrowly, unlike the broad powers presumed

  to be afforded under a medical durable power of attorney.” Id.; see

  also Moffett v. Life Care Ctrs. of Am., 187 P.3d 1140, 1145 (Colo.

  App. 2008) (“[A]bsent a limitation in the medical durable power of

  attorney, an attorney-in-fact can make exactly the same types of

  medical treatment decisions that the principal could make if he or

  she had the mental capacity to do so.”), aff’d, 219 P.3d 1068.

¶ 42   Lujan’s reasoning is not limited to cases involving health care

  proxies, which are executed on behalf of a patient who “lacks

  decisional capacity to provide informed consent to or refuse medical

  treatment.” 222 P.3d at 972. The division in Lujan noted the “clear

  legislative intent to distinguish between an agreement to provide

  medical services (including an agreement to admit a patient to a

                                    22
  health care facility) and an agreement to arbitrate a health care

  dispute.” Id. at 974 (citing § 13-64-403(7)).

¶ 43   For purposes of the health care proxy provisions at issue in

  Lujan, “medical treatment” means “specific medical procedures

  (e.g., artificial nourishment and hydration) or forms of healing (e.g.,

  religious and spiritual healing).” Id. (citing § 15-18.5-101(1)(a), (2),

  C.R.S. 2021). In addition, the part of the probate code addressing

  powers of attorney similarly defines “‘medical treatment’ as ‘the

  provision, withholding, or withdrawal of any health care, medical

  procedure, including artificially provided nourishment and

  hydration, surgery, cardiopulmonary resuscitation, or service to

  maintain, diagnose, treat, or provide for a patient’s physical or

  mental health or personal care.’” Id. at 973 (quoting

  § 15-14-505(7), C.R.S. 2021).

¶ 44   According to the division in Lujan, under either definition, an

  agent’s authority to make decisions regarding a patient’s “medical

  treatment” does not encompass the authority to sign an arbitration

  agreement. Id. at 974. Importantly, the division in Lujan held that

  a decision to execute an arbitration agreement “is not integral to a

  patient’s health and well-being.” Id. at 976. Instead, a decision to

                                     23
  arbitrate pertains exclusively to a person’s legal rights and

  remedies. See Colo. Const. art. XVIII, § 3; §§ 13-22-201 to -230,

  C.R.S. 2021. Thus, a decision to arbitrate, or not to arbitrate, is

  fundamentally different from a decision involving medical

  treatment.

¶ 45   In examining the scope of the authority granted to an agent

  through a health care proxy, the Lujan court noted section

  13-64-403(7)’s express prohibition on conditioning the provision of

  medical services upon execution of an arbitration agreement.

  Lujan, 222 P.3d at 974. The General Assembly’s decision to delink

  the concept of arbitration from the concept of providing medical

  services underscores that granting an agent authority to make

  medical care decisions for a patient does not authorize the agent to

  waive the patient’s right to seek relief in a court of law. Thus, the

  authority of an agent to execute an arbitration agreement on behalf

  of a patient must rest on a source other than the agent’s

  authorization to make health care decisions for the patient.

¶ 46   Following the compelling logic of Lujan and the language of the

  Act, we hold that an agent’s actual authority to make health care

  decisions for a patient and to sign the documents necessary to

                                    24
  admit the patient to a health care facility does not encompass the

  authority to bind the patient to an arbitration agreement, unless

  the patient has granted the agent an unlimited power of attorney or

  otherwise clearly granted the agent the specific authority to bind

  the patient to an arbitration agreement. Thus, we conclude that, as

  a matter of law, the scope of Fresquez’s actual authority did not

  extend to binding Trujillo to the arbitration agreement. In light of

  our holding, we need not consider whether the district court erred

  by holding that Fresquez lacked authority to bind Trujillo to the

  arbitration agreement under the rule of equal dignities.

                 D. The District Court Did Not Err By
              Finding That Fresquez Lacked Apparent Authority

¶ 47   Having concluded that Fresquez lacked actual authority to

  bind Trujillo to the arbitration agreement, we next review the

  district court’s determination that he also lacked apparent authority

  to do so. “The issue of apparent authority is generally an issue of

  fact to be determined by the trial court.” Rush Creek, 107 P.3d at

  406. Apparent authority can apply to “agents who act beyond the

  scope of their actual authority.” Restatement (Third) of Agency

  § 2.03 cmt. a.

                                    25
¶ 48   We conclude that the district court did not clearly err by

  making this finding.

            1.   Fresquez Did Not Have Apparent Authority to
                  Bind Trujillo to the Arbitration Agreement

¶ 49   The Trinidad defendants argue that the district court erred by

  requiring that “a principal’s manifestation of an agent’s authority to

  act be made prior to the act in question.” They contend that the

  district court improperly inserted a temporal requirement into the

  apparent authority analysis by considering only Trujillo’s

  statements and conduct preceding Fresquez’s execution of the

  arbitration agreement. They further argue that the Restatement of

  Agency rejects this temporal requirement by providing that

  apparent authority “applies to any set of circumstances under

  which it is reasonable for a third party to believe that an agent has

  authority.” Restatement (Third) of Agency § 2.03 cmt. c (emphasis

  added).

¶ 50   We need not consider the timing of a principal’s

  manifestations of an agent’s apparent authority, however, because

  the record lacks any evidence that Trujillo ever gave any

  manifestations regarding arbitration. As the district court found,

                                    26
  Trujillo generally knew of and authorized Fresquez to sign the

  documents and make the decisions related to her admission to and

  care at Trinidad Inn, both before and after she moved in. But the

  Trinidad defendants could not have reasonably believed that

  Fresquez also possessed apparent authority to sign the arbitration

  agreement on Trujillo’s behalf.

¶ 51   The district court based its finding that Fresquez lacked

  apparent authority to bind Trujillo to the arbitration agreement on

  the testimony of the social services assistant and Fransua, Trinidad

  Inn’s administrator, at the hearing. Those employees conceded

  that, before Trujillo’s admission to Trinidad Inn, she did not make

  any manifestation to them, whether by word or deed, that Fresquez

  was authorized to bind her to the arbitration agreement.

¶ 52   Indeed, nothing Trujillo said or did at any time suggested that

  she was aware of the arbitration agreement or that she intended to

  grant Fresquez the authority to sign away her right to a trial in a

  court of law. Moreover, the record does not contain any evidence

  suggesting that Trujillo ever learned of the existence of the

  arbitration agreement.

                                    27
¶ 53   The social services assistant’s and Fransua’s testimony does

  not indicate otherwise. The social services assistant testified that

  (1) she received paperwork from Trujillo’s referring doctor saying

  that Trujillo’s “attorney” wanted Trujillo to move to a nursing home;

  (2) the social services assistant coordinated Trujillo’s move to

  Trinidad Inn with Fresquez; and (3) Fresquez signed the admission

  documents while Trujillo settled into her room. Fransua testified

  that she believed Fresquez was Trujillo’s representative for purposes

  of signing the arbitration agreement because he “was present with

  [Trujillo] in asking [the primary care physician] for the nursing

  home placement,” and he and Trujillo “work[ed] towards that goal of

  getting [Trujillo] in the nursing home.” This testimony supports the

  district court’s finding that Fresquez lacked apparent authority to

  bind Trujillo to the arbitration agreement.

¶ 54   Although the district court found that Fresquez told the

  Trinidad defendants he was Trujillo’s attorney-in-fact, neither the

  social services assistant nor Fransua ever saw such a power of

  attorney. (A power of attorney must be in writing. See Willey, 876

  P.2d at 1264 (explaining that a power of attorney is “a written

  document by which one party, as principal, appoints another as

                                    28
  agent (attorney-in-fact) and confers upon the latter the authority to

  perform certain specified acts or kinds of acts on behalf of the

  principal”).)

¶ 55   Further, the Trinidad defendants contend that the purpose of

  the apparent authority doctrine is to “protect[] third parties who, in

  good faith, rely on their belief that an agency relationship exists

  between the apparent principal and agent.” See Villalpando, 181

  P.3d at 363. But nothing in the record shows that they relied on

  their belief that Fresquez possessed the authority to bind Trujillo to

  the arbitration agreement. As noted in Part II.B.1 supra, Trinidad

  Inn could not have refused admission to Trujillo even if the Trinidad

  defendants learned at the time that Trujillo had not executed a

  power of attorney. Thus, consistent with section 13-64-403 of the

  Act, the validity of the arbitration agreement, and Fresquez’s

  authority to bind Trujillo to it, was of no consequence to Trinidad

  Inn’s decision to admit Trujillo.

¶ 56   The Trinidad defendants further assert that their reliance on

  Trujillo’s manifestations following Fresquez’s execution of the

  arbitration agreement “caused [them] to forebear pressing further

  for the power of attorney . . . or to request a signature from . . .

                                      29
  Trujillo” on the arbitration agreement. But nothing in the record

  supports this assertion.

¶ 57   Indeed, the social services assistant asked Fresquez to provide

  her with a copy of the power of attorney after Trujillo’s admission.

  But she dropped the subject after contacting him about it “a few

  times.” The social services assistant’s testimony undercuts the

  Trinidad defendants’ argument that Trujillo’s manifestations caused

  them to forebear pressing Fresquez further for the purported power

  of attorney. The social services assistant did not say that she

  stopped asking Fresquez for the power of attorney based on

  anything Trujillo said or did. And nothing in the record indicates

  that Trujillo would have signed the arbitration agreement if Trinidad

  Inn had asked her to do so or that Trujillo’s manifestations induced

  the Trinidad defendants not to ask her to sign it.

¶ 58   In sum, Trujillo’s words and actions indicated only that

  Fresquez possessed the authority to make decisions related to

  Trujillo’s medical care and her admission to Trinidad Inn. Trujillo

  never made any manifestations indicating that Fresquez also had

  the authority to bind her to the arbitration agreement. See Lujan,

  222 P.3d at 976. Thus, we affirm the district court’s determination

                                    30
  that Fresquez lacked apparent authority to execute the arbitration

  agreement on Trujillo’s behalf.

         2.    Trujillo Did Not Ratify the Arbitration Agreement

¶ 59   For the same reasons, we conclude that Trujillo did not ratify

  the arbitration agreement. The Trinidad defendants argue that,

  even if Fresquez lacked apparent authority to bind Trujillo to the

  arbitration agreement, Trujillo later ratified his execution of the

  arbitration agreement through her “knowledge that [Fresquez] was

  making decisions on her behalf without objection — even without

  specific knowledge of the [arbitration agreement].”

¶ 60   Ratification occurs “when a party ‘with knowledge of all

  material facts’ adopts and confirms an act performed or entered

  into on his behalf by another, without authorization.” Fiscus v.

  Liberty Mortg. Corp., 2014 COA 79, ¶ 40, 373 P.3d 644, 652

  (quoting Siener v. Zeff, 194 P.3d 467, 471 (Colo. App. 2008)), aff’d

  on other grounds, 2016 CO 31, 379 P.3d 278. Here, Trujillo did not

  possess “full knowledge of all material facts.” Id. The district court

  did not find that Trujillo ever knew of the existence or terms of the

  arbitration agreement.

                                    31
¶ 61   Therefore, we conclude that Trujillo did not ratify Fresquez’s

  execution of the arbitration agreement.

                            III.   Conclusion

¶ 62   The order denying the Trinidad defendants’ motion to compel

  arbitration is affirmed, and the case is remanded for further

  proceedings consistent with this opinion.

       JUDGE NAVARRO and JUDGE KUHN concur.

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