Q:
While it is the resident’s right to refuse care, what are the responsibilities of the facility when this occurs?
A:
As we see in the Federal Regulatory Grouping §483.10 Resident Rights, the resident absolutely has the right to refuse care. This is specified in §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. However, simply stating “the resident refused care” 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”. There are many factors the facility must consider and document to support the efforts being made to overcome the possible negative consequences of refusals.
One of the most important first steps to take is to ensure that the resident and their representative have been adequately informed and educated on the aspects of care being presented. Are they fully aware of the benefits and the potential risks of the offered interventions, and the possible risks of refusal? They must be able to understand the consequences of the decisions they make in accepting or refusing the care. Have they been given adequate time to ask all questions they may have, and have they been made aware of any alternatives that are available? Frequently, the easiest way to overcome a refusal is to offer substitute options that are equally effective. Knowing the resident and their likes/dislike, and brainstorming as a team, will be the best way to determine what alternatives may be successful.
It is equally important to understand that when a resident refuses care/treatment, the facility cannot treat them against their wishes. The facility must make every effort to determine what is causing the resident to refuse, “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”. For example, a resident who is refusing to turn in a certain direction to prevent skin breakdown, may be refusing because they cannot see the television or out the window when they are facing that side. Perhaps moving the bed or tv to a location where it can be seen from either direction would be in order.
It is essential that these type of specific resident interventions be addressed on the care plan and communicated to all staff. They will only be effective if consistently implemented and shared with all caregivers.
The facility must also ensure that it has policies and procedures in place that protect the right of the resident to refuse care. Staff must be educated on these policies and procedures to make sure they understand that what they feel is in the best interest of the resident, may not be the resident’s choice. They should also be provided with training on how to offer options/alternatives when a resident refuses, and where a list of the resident specific options can be found on the care plan/Kardex. By working together as a team, we can determine that resident needs are met, even when they exercise their right to refuse.
Janine Lehman, RN, RAC-CT, CHC
Director of Legal Nurse Consulting
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