Refusal of Care & Non-Adherence to Care Plan

Addressing Refusal of Care and Non-Adherence to Care Plans in Skilled Nursing Facilities: Strategies for Success

Refusal of care and non-adherence to care plans by residents in Skilled Nursing Facilities (SNFs) present significant challenges for healthcare teams. When residents reject the care or therapies prescribed, it can lead to adverse health outcomes, increased risk of rehospitalization, and compromised quality of life. For Administrators, Directors of Nursing (DONs), MDS coordinators, social services, and therapy departments, managing these situations effectively requires a thoughtful, multidisciplinary approach.

Why Residents Refuse Care:

Understanding the reasons behind refusal of care is crucial in addressing the issue. Some common reasons include:

• • Lack of understanding: Residents may not fully grasp the purpose or importance of certain treatments or interventions.
  • Fear or anxiety: Procedures may cause discomfort or fear, leading to rejection.
  • Cultural or personal preferences: A resident’s cultural background or personal beliefs might influence their willingness to comply with the care plan.
  • Cognitive impairments: Conditions like dementia can make it difficult for residents to process instructions or understand the importance of following through with care.
  • Loss of autonomy: Some residents feel a loss of control over their own lives and may refuse care as a way to assert independence.

Legal and Ethical Considerations:

While respecting resident autonomy is critical, SNFs must also ensure residents receive the care necessary for their well-being. The Resident Bill of Rights guarantees residents the right to refuse treatment, but it is equally important to balance this with the duty of care outlined in the care plan.

SNFs must follow a documented, collaborative approach when managing refusal of care, ensuring that all care team members—administrators, nursing staff, therapists, and social workers—are aligned. Proper documentation is essential to protect the facility from liability while ensuring all efforts are made to meet the resident’s needs.

Strategies to Address Refusal of Care:

• • Open Communication

• • • Engage residents in conversations about their care. Use simple language, and if the resident has cognitive limitations, consider family involvement or a proxy decision-maker. Social workers can help facilitate these conversations, ensuring that residents’ concerns or fears are acknowledged and addressed.

• • Education and Understanding
    • Provide education to residents about the importance of treatments or therapies. Therapy and nursing staff should take time to explain the purpose of interventions, potential benefits, and risks of non-adherence. Utilize tools like visual aids or demonstrations to enhance understanding.

• • Involve Residents in Decision-Making
    • Encouraging resident involvement in the creation of their care plan helps them feel a sense of ownership and control. Allow them to voice their preferences and incorporate these into the care plan as much as possible. For instance, offering alternatives to therapies or adjusting schedules may reduce resistance.

• • Multidisciplinary Team Approach
    • A collaborative approach is key. Therapy departments, nursing, social services, and administration should communicate openly about resident refusals. If a resident refuses physical therapy, for example, therapy staff can report the refusal to the DON, MDS coordinator, and social services, who can then work together to identify root causes and develop an intervention plan.
    • Regular case management meetings, including a focus on residents with a history of non-adherence, can help the team stay proactive in addressing ongoing or escalating issues.

• • Behavioral Interventions
    • Some refusals may be rooted in behavioral health concerns, such as depression or anxiety. Social services can play a critical role in assessing these concerns and facilitating access to mental health services. In some cases, a referral to psychiatry or counseling may be beneficial to support the resident’s overall well-being and compliance.

• • Personalized Care Plans
    • Care plans must be individualized to reflect the unique needs, preferences, and limitations of each resident. MDS coordinators, in collaboration with nursing and therapy teams, should ensure that care plans are updated regularly and reflect any changes in the resident’s condition or preferences. Flexibility is key to fostering adherence.

• • Document, Document, Document
    • It cannot be stressed enough: thorough documentation is critical when a resident refuses care. This protects the facility from potential legal repercussions and provides a record of the facility’s attempts to educate, communicate, and accommodate the resident’s preferences. MDS coordinators should be vigilant in ensuring that refusals are properly captured in assessments and that the resident’s care plan is updated accordingly.

• • Involving Family and Caregivers
    • Engaging the resident’s family or caregivers can often facilitate better compliance. Families can provide valuable insights into the resident’s preferences or help reinforce the importance of adherence to care. However, this involvement must always be respectful of the resident’s right to autonomy.

Leveraging Technology for Better Outcomes:

Modern technology can assist SNFs in managing non-adherence more effectively. Electronic health records (EHR) allow real-time documentation of care refusals and facilitate better communication among interdisciplinary teams. By flagging refusal patterns, EHRs can help staff proactively address issues and adjust care plans before complications arise.

Additionally, remote monitoring tools can help track vital signs, movements, or therapy participation, allowing caregivers to follow up in cases where adherence might be compromised.

Conclusion

Addressing refusal of care in SNFs is a complex but essential part of delivering quality healthcare. For administrators, DONs, MDS coordinators, social services, and therapy departments, a combination of education, communication, behavioral support, and personalized care planning is crucial to overcoming these challenges. By fostering a culture of collaboration and respect for resident autonomy, facilities can ensure that residents receive the care they need while maintaining their dignity and independence.

Refusal of care will always be a challenge in long-term care, but with a proactive, compassionate, and interdisciplinary approach, SNFs can improve compliance, enhance resident outcomes, and minimize the risks associated with non-adherence.