Adequately Documenting Refusal of Care

Denise GillinRisk Management, Senior Living

By Cathy Knopf, BSN, RN for

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.

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