Adequately Documenting Refusal of Care

The law requires senior living communities to “promote and protect the rights of each resident” and places a strong emphasis on individual dignity and self-determination. These rights include the right to refuse treatment or services. Healthcare staff are placed in a precarious position when the resident exercises this right. They are tasked with honoring the resident’s wishes while still providing other care that allows him / her to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. For example, healthcare 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.

It is important to appropriately document resident choices within the medical record. General best documentation practices include:

• Clear, concise, factual, objective verbiage
• Comprehensive assessment
• Descriptive interventions
• Timely monitoring
• Communication with healthcare practitioners, resident, and legal representatives

More specifically, when it comes to refusal of care, ensure the medical records includes documentation to support communication with resident and legal representative regarding:

• The problem needing care or services
• The proposed treatment, medication, or diagnostic test
• The anticipated benefits, risks, and complications of the proposed care or services
• The risk and possible consequences of refusing the care or services
• The reason(s) for refusal
• The staff’s follow-up attempts to provide the ordered treatment/care along with the resident’s acceptance or declination of the treatment/care
• The staff’s conversations with the resident’s attending physician or primary care physician regarding the resident’s refusal of ordered care and treatment and possible alternatives to address the resident’s needs
• Delivery of care to attain or maintain highest practicable physical, mental, and psychosocial well-being.

Clear, concise, and factual documentation within the resident’s medical record mitigates regulatory citations, insurance claims and litigation, as does documented conversations with the resident’s family or responsible party regarding refusals of care. For additional information regarding documentation strategies, contact an AssuredPartners Senior Living insurance professional.