MDS Alert

Understanding residents’ rights can help you be proactive instead of reactive.

Navigating the appropriate steps for an unplanned discharge or rejection of treatment may be overwhelming or confusing. Know these important steps about your responsibilities as an MDS coordinator in such situations.

Caveat: There’s no one-size-fits-all rule to follow here in terms of discharge because local rules probably apply too.

Familiarize Yourself with the Nuts and Bolts

When dealing with an Against Medical Advice situation (AMA), especially when it pertains to leaving the facility, know the difference between various discharges and why certain rules are in place.

“There are two types of discharge assessments, the Discharge Assessment – Return not Anticipated and Discharge Assessment – Return Anticipated. The former needs to be completed when the resident is discharged from the facility and not expected to return to the facility within 30 days, which may likely be the case when a resident leaves AMA,” says Linda Elizaitis, RN, RAC-CT, BS, president of CMS Compliance Group Inc. in Melville, New York.

“If a resident decides to leave the facility Against Medical Advice (AMA), this is considered an unplanned discharge, so an MDS Discharge assessment still needs to be completed by the facility to the best of its ability,” Elizaitis explains.

Though the discharge planning requirements are outlined at the federal level through the Requirements of Participation (RoPs), facilities are “instructed to follow their policies or state law related to these types of discharges,” she says.

However, the MDS coordinator is responsible for evaluating a resident’s goals and expectations when completing the MDS.

“The MDS coordinator’s role is not simply reactive in this case,” Elizaitis emphasizes.

The MDS is the groundwork for the facility’s relationship with the resident.

“Items such as Q0300 (Resident’s Overall Expectation) are utilized to understand the resident’s goals and expectations. In particular, gaining an understanding of the resident’s expectations about returning to the community — realistic or not — can provide much needed insight into how the facility needs to address the resident’s needs and preferences. The resident’s clinical record should reflect this information,” she says.

Provide Informed Consent to Reduce Treatment Refusal

Part of patient-centered care is reinforcing a resident’s participation in and consent for her own care.

“Federal regulations also set out the requirements for residents to participate in planning their care as well as to refuse treatment,” Elizaitis says.

Surveyors can cite facilities with various Ftags if they feel that residents aren’t duly informed of care and services: “F552 Right to be Informed/Make Treatment Decisions provides residents with the right to be informed in advance of care and services to be provided, as well as information related to risks/benefits/alternatives so that the resident can choose the option that he or she prefers,” she says.

Part of the facility’s and staff’s responsibilities is keeping residents informed about their care, including keeping them up-to-date on any changes.

“The resident continues to retain the right to participate in care planning, including the right to see his or her care plan after significant revisions have been made, so as to allow the resident to decide if this is the course he or she wishes the facility to take, which is part of F553 Right to Participate in Planning Care,” Elizaitis says.

Refusing treatment is encompassed within residents’ rights, too, and staff must document any refusal of treatment clearly in the clinical record. ““If the resident has declined treatment, he or she may not be treated against his wishes, so this needs to be documented in the clinical record thoroughly,” Elizaitis says.

“The RoPs state that under F578, the resident has the right to refuse and/or discontinue treatment. However, the Interpretive Guidance (IG) notes that this refusal does not absolve the facility’s staff from providing other care that may be necessary,” she adds.

Don’t forget to look at the full trajectory when evaluating care and treatment per residents’ wishes.

“The resident’s advance directive also provides insight into the resident’s expectations for treatment, so it’s important that this is periodically reviewed with the resident. The clinical record is a living document, and residents may choose to decline treatment or services depending on circumstances as they change, so the record needs to reflect those preferences and provide the necessary documentation to show that alternatives were recommended if available and that the resident/representative were educated on the available options,” Elizaitis says.