What are some best practices for residents who refuse care?



In the CMS State Operations Manual – Appendix PP in F 578 §483.10(c)(6), (c)(8), (g)(12) CMS has provided guidance regarding resident refusals:

      • While the resident also has the right to refuse any treatment or services, the resident’s refusal does not absolve facility staff from providing other care that allows him/her to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. For example, facility staff would still be expected to provide appropriate measures for:
        • Pressure injury prevention, even if a resident has refused food and fluids and is nearing death.
        • If a resident (directly or through an advance directive) declines treatment (such as refuses artificial nutrition or IV hydration, despite having lost considerable weight), the resident may not be treated against his or her wishes.
        • If a resident is unable to make a health care decision, a decision by the resident’s legal representative to forego treatment may be subject to State requirements, be equally binding on the facility. A resident may not be transferred or discharged for refusing treatment unless the criteria for transfer or discharge are otherwise met.
        • Facility staff should attempt to determine the reason for the refusal of care, including whether a resident who is unable to verbalize their needs is refusing care for another reason (such as pain, fear of a staff member, etc.), and address the concern, if possible. Any services that would otherwise be required, but are refused, must be described in the comprehensive care plan.


Some tips for how to implement this guidance include:

  • Make sure you have addressed the resident refusal concerns in the assessments and on the Care Plan.
  • Do your best to identify the reasons for refusals.
  • Try to determine and implement alternatives to refused care.
  • Actively involve the family/resident representative in addressing care refusals.
  • Consult with the primary physician – can orders be changed giving consideration to alternatives the resident will accept?
  • Consider psychiatric consultation services.
  • Continuously educate the resident on the consequences of their refusals, and document this education along with the resident response.

Janine Lehman, RN, RAC-CT, CLNC
Director of Legal Nurse Consulting

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