Interpreting and Responding to Refusal of Care

A male resident at an assisted living facility had earned a reputation for being cantankerous and independent. He was diagnosed with dementia and suffered worsening cognition. After a fall, he was hospitalized before being discharged back to the facility.

The staff tried to assist him with transfers and showers, but he was hostile toward the staff during every attempt. The staff documented these incidents as refusal of care. The resident stayed in his bed and refused to get up. He frequently insulted any staff member who encouraged him to walk around. The staff also documented this.

The man’s family became understandably worried about his condition and decided to take him back to the hospital. It was then that he was diagnosed with a fractured hip.

This case illustrates how easy it is to misinterpret refusal of care. The facility staff likely assumed that the resident was acting out because he was cantankerous, desperate to stay independent, and suffering from worsening dementia. In hindsight, though, it is clear that he was lashing out because he was in significant pain, which he may have been unable to communicate clearly due to his dementia.

How Misunderstandings Lead to Liability

Residents don’t always act in their own best interests. In some cases, they refuse the care they need, leaving facility staff with no options. However, it’s important to consider all the possible reasons behind the refusal.

Even if no negligence contributed to the resident’s health condition, your staff could be liable for failing to respond appropriately. This is true in any situation, including those that involve apparent noncompliance. In a situation like the one above, some missteps could lead to liability. These include failing to inform the:

• Family of the incident. Imagine finding out that your parent or grandparent has been in pain for weeks and the assisted living facility never notified you. After a fall or other incident, it’s important to notify the family immediately to allow family members to check on their loved one and advocate on their loved one’s behalf.
• Physician of a change in condition. Having a doctor check a resident once may be insufficient. If the resident’s condition changes, the doctor needs to know.
• Family of a change in condition. Just as you should notify the family of incidents, it’s important to notify them of changes in condition.
• Other staff of a change in condition. Every facility needs effective communication practices to prevent serious issues from falling through the cracks. You should document any issues or changes in condition in a way that ensures other staff members will see the information.

When Responding to Care Refusal, Communication is Key

Educate your team to stay on the lookout for signs that a resident is in pain. Your facility can help keep residents safe and avoid liability by implementing policies and procedures regarding how to handle noncompliance. Most of these policies come down to communication – with healthcare providers, with the resident’s family, within the facility, and with the resident.

• Document any incidents of noncompliance and refusal of care. If there are any accusations against your facility, documentation will provide evidence that you were doing everything possible to provide care. Documentation also helps staff members provide consistent care and keep track of issues across shift changes.
• Keep the resident’s family informed. It’s important to keep the family in the loop. Otherwise, they won’t be able to help their loved one and may accuse your facility of trying to cover up problems.
• Notify the resident’s doctor of any noncompliance with recommended care or changes in condition. Even if the resident has been discharged, additional care may be necessary, but the doctor can’t make any recommendations without having the full picture.
• Be cognizant of communication problems with the resident. Dementia and other health conditions may impede a resident’s ability to communicate. When residents are uncooperative or hostile, consider the possibility that they may be lashing out in pain and frustration.

The bottom line: If staff cannot provide necessary care to a resident due to noncompliance, it’s important to address the issue. Do not hesitate to refer the resident to a physician. If that proves inconclusive, request a psychological evaluation – and keep the resident’s family informed throughout.

Although these steps will help you reduce liability, it’s still important to maintain assisted living facility insurance. Tangram provides residential care facility insurance through the Personal Care & Assisted Living Insurance Center (PCALIC). Learn more.