Long-Term Care Survey Alert

IJ case highlights the hazards of mishandling this common problem.

A resident at high risk for skin breakdown refuses to be turned and repositioned.How you handle this or similar scenarios can mean the difference between whether you end up with IJ citations and lawsuits or not.

Cautionary tale: Defense attorney Meg Pekarske is dealing with a nursing home case where a non-geriatric man with mental illness diagnoses developed a stage 4 pressure ulcer resulting from his non-compliance with the care plan. "He refused the turning and repositioning schedule and wouldn't eat better and takesupplements," says Pekarske, with Reinhart Boerner Van Deuren in Madison, Wis.

The facility got cited not because the resident refused care but rather because it lacked sufficient documentation showing staff educated the patient about the "ramifications of his choices," Pekarske says. You have to show that "staff had repeated conversations with him letting him know that if he didn't turn and reposition,his pressure ulcer could advance to a stage 4 or he could lose his leg or get a lethal infection."

And you need to have "more than one documented conversation [with the patient] about the risk-benefits of his choice -- especially when ...things are getting worse,"Pekarske says. "Someone may decline an intervention initially but as they develop more debilitating symptoms or pain, they may be more open to the intervention(s)."

Also: The interdisciplinary team should assess and address why the person is refusing the care, advises Cindy MacQuarrie, RN, MN, managing consultant for BKD LLP in Kansas City, Mo. Is it depression, a sense of hopelessness, pain, lack of involvement in the facility or a misunderstandingof the prognosis?

Consider using a flow sheet forma to document the times that staff attempted to provide care and the resident's refusal, suggests MacQuarrie. You could use the same documentation flow chart format to document care provided to other residents, she adds. "This type of documentation demonstrates that facility staff has attempted to provide care outlined in the care plan" rather than "just failing to provide treatment," MacQuarrie points out.

In addition to continuing to offer the care plan interventions designed to prevent skin breakdown or heal a pressure ulcer, try to find alternatives that the resident will accept, Pekarkse advises. Examples include ordering a special mattress if the person won't reposition often enough. You can also offer "super food" type alternatives that pack large amounts of nutrients in a small portion.

Sometimes you have to "think out of thebox," adds Pekarske. For example, one facility care planned to have a resident come to the nursing station to get his meds in order to encourage him to get up and move more, she notes.

Should the facility ask the resident or responsible party who refuses care to sign an informed consent document and waiver of liability? "It depends on the significance of the issue," counsels Pekarske.

"Oftentimes, summarizing the conversations in the medical record will be enough." If the "ramifications of [the resident's] choice are very significant," however, the facility may want to use a formalized procedure, she adds.

Best bet: Facilities should "work with their legal counsel and insurers to discuss various risk-management strategies, including obtaining written informed consent and a waiver of liability," Pekarske advises.