I was recently asked by surveyors, “how do you know that a cognitively impaired resident is refusing care/treatments just because they are saying “No! No!”?

We know that without cognitive impairments, “No” means exactly that – NO. But when a resident who is severely impaired in making daily decisions, hits staff during daily cares and swears at staff with each physical contact on multiple occasions per day, or toward multiple care givers, and the behavior is not easily altered – would this not be considered NO? Absolutely!

However, when this type of reaction occurs - verbal and/or physical resistence- this should be further investigated so that the care plan can address the situation and alternative methods for providing needed care can be implemented. This exhibited reaction may be a fear of falling, pain, past experience with care givers or just the inability to comprehend the intended action.

Direct care staff need to be sure that when this type of refusal is being exhibited, it is addressed by: 1. providing a safe environment and leaving the resident, 2. Report it to the nurse, 3. document the reaction to the interaction and what approaches and interventions were tried, 4. attempt the interaction again with a different staff member, and lastly 5. always respect the resident’s right to choose and refuse.

If this type of behavior is being noted and reported during the seven day observation period for the MDS, be sure it is accurately coded and addressed.

MDS Coding Tip of the Week for July 23rd, 2007
By: By: Bert O’Shaughnessy, RN