I need to know if I have the right to refuse care

Nurses General Nursing

Published

I am a new CNA, and first I want to say that nothing in class comes anywhere close to the real job. We were all informed of our rights and patient rights, but I need advice on a bad situation. Keep in mind, I have been working for 4 days at this point, fresh out of training, and have been given the full list of 11 residents that was the responsibility of a CNA that just abruptly quit.

I have a LTC patient who is verbally abusive and refuses all care when you ask to bathe or change her. The charge nurse on my shift told me that I am not allowed to listen to her refusal for care and that instead of asking I just have to tell the patient that I am going to do it either way. The nurse forced me to do this today. When within reach of the resident she scratches and digs her nails into arms, hands, cheeks, anything she can get ahold of, drawing blood with almost every scratch. Six hours since the nurse made me do this and the scratches are still bright red all up and down my arms. If she can't get an arm she will smack you in the back of the head full force. I was advised to hold her hands down, which I know from class is a restraint. And either way, if her hands are held down she raises her legs and drives her knees into your stomach as hard as she can. I am 9 weeks pregnant and my employer knows that. I cannot be kneed in the stomach.

This patient refuses care, which I know is her right. My question is, is it within my rights to refuse to go against her wishes even if the nurse commands me to? Is it within my rights to refuse care if she is combative and I feel that the safety of my baby is in danger?

I don't want to risk abandonment or neglect charges, but the resident is blatantly refusing care. If she refuses care then she should not be forced. But I also don't want insubordination accusation from the nuse on my hall. I am also unwilling to risk my baby's safety.

I just need to know what is within my rights to do here.

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If the patient is confused, and hopefully she is (considering her behavior), it's a tricky situation. If she's allowed to refuse care in that state, she could end up being seen as a victim of neglect.

That being said, it's not reasonable to expect to be scratched, hit and kicked every time you provide care. It sounds like this patient needs her medications to be reviewed and adjusted- for her own good as well as for your own.

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Now we know why the previous CNA "abruptly quit".Yes, the patient can refuse care if they are competent.Clearly, she is not.

Nurses cannot "command" you. The facility has failed the patient and the staff by allowing this to continue.

Request a patient care conference, include all disciplines. The doctor and social worker need to know the scenario. If you are not comfortable doing so, go one step above the commando nurse and request assistance in handling the situation.

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The problem is, where I just started working right out of training, I'm only supposed to be assisting another CNA right now. Legally, I am not licensed to work on my own yet. The nurse doesnt force medications when the patient refuses, so I don't see how I am supposed to force bathing or changing when she refuses. As far ad i know the patient is not confused. She knows where and who she is and who the staff members are, she just gets violent if anyone tries to disturb her, and to her basic care is considered a disturbance. I dont know her condition 100% because as a CNA we arent outright informed of conditions and the nurse will barely speak to me even when i ask questions. No one is in our offices on weekends, and even if they were I don't know who to go to.

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Specializes in LTC/Rehab, Pediatric Home Care.
The problem is, where I just started working right out of training, I'm only supposed to be assisting another CNA right now. Legally, I am not licensed to work on my own yet. The nurse doesnt force medications when the patient refuses, so I don't see how I am supposed to force bathing or changing when she refuses. As far ad i know the patient is not confused. She knows where and who she is and who the staff members are, she just gets violent if anyone tries to disturb her, and to her basic care is considered a disturbance. I dont know her condition 100% because as a CNA we arent outright informed of conditions and the nurse will barely speak to me even when i ask questions. No one is in our offices on weekends, and even if they were I don't know who to go to.

If she is A&Ox3, understands her situation, and does not appear to be in any immediate danger, I would not try to force her to do anything. If you two are struggling and she gets hurt in the process, she could possibly claim abuse and you won't have a leg to stand on. I would first, report it to your nurse. Perhaps you two can try to reason with her (most likely won't work based on what you described). If that is not successful, speak with management and let them know what is going on. More then likely a care plan meeting needs to be set up, to find out why she is refusing care and what can be done about it. If management is unwilling to help you out, consider changing jobs.

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Specializes in critical care.

OP, I agree there is a grey area. Grey for caring for the patient. NOT grey for you. Make your employer aware of your pregnancy. If you can't get off this patient assignment, which is known to be physically dangerous, you have cause for a grievance. You should not be forced to place your baby in harm's way to keep your job.

And I also want to voice to you that as a nurse, I can delegate to a CNA, but I am not the CNA's boss. The CNA cannot be "ordered" by me to do anything. Out of professional courtesy, I would hope he or she would talk to me if there is something they can't or won't do, but I can't discipline them in any way for not listening. All of the nursing care of the patient is on MY shoulders, not the CNA's. I also don't think abandonment charges can be brought onto aides. At least not in my state. Look it up in yours.

If you have questions, I'm sure the instructor of the program you just completed can either answer them, or find you applicable resources.

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OP, I agree there is a grey area. Grey for caring for the patient. NOT grey for you. Make your employer aware of your pregnancy. If you can't get off this patient assignment, which is known to be physically dangerous, you have cause for a grievance. You should not be forced to place your baby in harm's way to keep your job.

And I also want to voice to you that as a nurse, I can delegate to a CNA, but I am not the CNA's boss. The CNA cannot be "ordered" by me to do anything. Out of professional courtesy, I would hope he or she would talk to me if there is something they can't or won't do, but I can't discipline them in any way for not listening. All of the nursing care of the patient is on MY shoulders, not the CNA's. I also don't think abandonment charges can be brought onto aides. At least not in my state. Look it up in yours.

If you have questions, I'm sure the instructor of the program you just completed can either answer them, or find you applicable resources.

OP's pregnancy has nothing to do with the situation.There are no health stipulations set aside for a pregnant caregiver ( unless special considerations are ordered by the OB-GYN) getting kicked in the stomach will not effect a 9 week pregnancy.. unless it's by a horse. Pulling the "I'm pregnant card" will only serve to aid her dismissal.

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Specializes in critical care.
OP's pregnancy has nothing to do with the situation.There are no health stipulations set aside for a pregnant caregiver ( unless special considerations are ordered by the OB-GYN) getting kicked in the stomach will not effect a 9 week pregnancy.. unless it's by a horse. Pulling the "I'm pregnant card" will only serve to aid her dismissal.

You think? I would think informing them of pregnancy would be more likely to protect her legally from being terminated for the pregnancy itself.

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I agree with the suggestion of a interdisciplinary care conference, including family if there is any, and it would be a good idea to get psychiatry involved. There needs to be some kind of consensus on whether this woman has the mental capacity to refuse care and medications (and there is more to capacity than just whether the individual is alert and oriented), and, if not, what the plan is for providing the care. This should not be left up to each individual staff member to make her/his own decision and fend for her/himself.

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It's up to you to read the facilities policies. Go to the front office and ask for them. Review chain of command, it should be in the policies somewhere.

In the meantime I would think that if you approach this person and are refused, wait a little bit and re approach. If you try a few times and aren't successful, inform the nurse.

Document refusal of care. Document combative behaviors. And document physical contact. Don't restrain her. Don't force her.

If there is no documentation it's going to be harder to get a care meeting set up.

Might also be a good idea to have another person go into the room with you.

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I agree with the suggestion of a interdisciplinary care conference, including family if there is any, and it would be a good idea to get psychiatry involved. There needs to be some kind of consensus on whether this woman has the mental capacity to refuse care and medications (and there is more to capacity than just whether the individual is alert and oriented), and, if not, what the plan is for providing the care. This should not be left up to each individual staff member to make her/his own decision and fend for her/himself.

This^

And I would also say that since the nurse knows that the patient is extremely combative I find it lousy that he/she didn't go in and help you to lessen the likelihood of injury. Poor teamwork.

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I agree with the suggestion of a interdisciplinary care conference, including family if there is any, and it would be a good idea to get psychiatry involved. There needs to be some kind of consensus on whether this woman has the mental capacity to refuse care and medications (and there is more to capacity than just whether the individual is alert and oriented), and, if not, what the plan is for providing the care. This should not be left up to each individual staff member to make her/his own decision and fend for her/himself.

Thank you.

My own mom is in a lock-down Alzheimers facility due to occasional violent outbursts that include physically attacking staff. For awhile she was in my local hospital but they had to pay Traveling CNA's to do one-on-one care with her because they didn't have enough staff. One time her physician had to restrain her from attacking a staff member.

She was moved 4 hours away to another facility that deals with this kind of patient and yes, my mom cannot be forced into a shower or forced to eat.

The facility she is in has been truly wonderful in addressing her outbursts and that entailed what elkpark said above. They changed her meds and worked with the staff to address her behavior and things are much better now.

I also agree that the nurse is not your boss. You are colleagues working together.

Please look into this further - it is difficult when you are brand new but don't let someone else dictate to you that you must force someone to do anything. Lots of good advice here.

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