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

Posted

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.

Pangea Reunited, ASN, RN

Has 6 years experience.

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.

Been there,done that, ASN, RN

Has 33 years experience.

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.

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.

Miss Rayanne

Specializes in LTC/Rehab, Pediatric Home Care. Has 9 years experience.

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.

Edited by Miss Rayanne

ixchel

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.

Been there,done that, ASN, RN

Has 33 years experience.

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.

ixchel

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.

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.

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.

NurseSpeedy, ADN, LPN, RN

Has 18 years experience.

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.

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.

Edited by Spidey's mom

VANurse2010

Has 6 years experience.

The patient needs to be seen by a psychiatrist and a medication regimen prescribed.

And no, you cannot leave a demented patient to stew in their own secretions/excretions just because they "refuse." That said, the nurse is not doing her job by throwing you to the wolves.

mrsboots87

Specializes in Neuro, Telemetry. Has 6 years experience.

Whether you can refuse care for a patient will be in your nurse practice acts for your state. I'm in AZ and we most certainly can refuse care if a patient if we feel it unsafe or if we feel we are bein abused. When an aid refuses to care for a resident, it is the nurses job to delegate to care to another aid or take over care themself. This is because the basic care of the patient is under the scope of a nurse and impacts their license. But also keep in mind that AZ employers can terminate without cause. So refusing care just because you can won't make employers too happy. I have refused care exactly one time and it was a resident who was lying about aids and getting report happy. She started getting snooty with my and calling me names then threatening to report me for made up things. I reported to the nurse. Filled out an incident report for the facility and I now don't provide that resident care. Another aid has been fired from a report they couldn't disprove since then. Had I just refused care for some silly reason, I probably would have been fired.

Anither er issue you are coming across is if the resident is confused or able to truly refuse care. Where I work, if a resident has their mind then they are aloud to refuse care and we chart as such. Then the nurse heavily documents the incident to cover everyone bum. But we also can't just let people refuse for days at a time and sit soiled and filthy. So we are still required to make multiple attempts at providing care or get someone to help convince the resident to consent to the needed care. If a resident is confused, then they can't refuse. We provide the care anyway. There's a gray area of what is restraint and what's not that we have to be careful of, but a resident can't just be neglected because they don't want care.

In your situation with a combative resident, you do need to seek help when caring for them. If they get a bruise from swinging on you and it is thought that you caused it, you need a second set of eyes there who can back you up. Otherwise you risk being reported for elder abuse. If the violent person is competent and your attempts at caring for them result in you bein harmed, then let the nurse know the patient has refused your care. If the nurse gets upset, state you refuse to attempt further care to that patient because it is causing you harm above what would be considered reasonable. I have been hit and scratched. It happens and is part of the job. But an overly combative resident is not ok. When they draw blood, unless you are in a psych unit where this can potentially be part of the job, then it's not acceptable. If this person is not of sound mind, then the nurse needs to get an order to essentially force a med so that appropriate care can be given safely.

When your or other aids are being beaten on by a violent resident it is not just unsafe for you. It is unsafe for the resident as well because they could inadvertently harm themself.

I agree that the resident needs a full evaluation and everyone including facility and family members need to sort out a plan foe taking care of her and the issues.

No aide or nurse should have to have scratches and bruises that are as bad as you have described. Are you trying to handle her yourself? I don't know if this is a possibility but could you suggest that there are at least two aides or a aide and a nurse that can help with doing care on this resident. Safety for resident as well as yourselves. Breaks my heart to think an aide would have to endure such abuse at her job

Tenebrae, BSN, RN

Specializes in Mental Health, Gerontology, Palliative. Has 9 years experience.

The patient needs to be seen by a psychiatrist and a medication regimen prescribed.

And no, you cannot leave a demented patient to stew in their own secretions/excretions just because they "refuse." That said, the nurse is not doing her job by throwing you to the wolves.

Its unclear so far whether this patient is demented or just a nasty person

I have a patient on my unit who is alert and orientated to TPP and who will regularly refuse care. She also will throw things, hit, kick and punch staff.

We will offer the opportunities for care. I will ensure she is offered multiple opportunities for care. If she refuses it is documented, management are advised. I will not have my CNAs physically abused by someone who has stated "I'm trying to make things as difficult as possible for the staff" or who laughed when I replied to her question of why I was standing behind her with "I'm standing here so you cant throw things at me"

We are very fortunate in that we have full support of management. It absolutely goes against the grain for me to leave someone in a wet pad, or dirty bed, but as previously stated this resident has the ability to do major serious harm to someone and I'm not having the staff put at risk.

On the one positive note, it appears that this patient may be getting sick of lying or sitting in dirty clothes and is agreeing to have her cares done much more regularly now.

hppygr8ful, ASN, RN, EMT-I

Specializes in Psych, Addictions, SOL (Student of Life). Has 19 years experience.

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.

Just a side note that psychotropic medication is considered chemical restraint and can't be used in the LTC setting to control behavior - Justification must be made for it's use with periodic reviews and titrations towards DC must be attempted. You can't just stick someone on medication for the convenience of staff.

in the case in point a care team and physician would have to justify use of psychotropics - stating all effeorts to figure out why Pt was combative, what therapeutic measures have been taken to remedy the problem and if the current placement is appropriate.

Just putting it out there -because everytime this subject comes up the firstthing people think of is chemical restraint.

Hppy

heron, ASN, RN

Specializes in Hospice. Has 40 years experience.

I agree with previous posters that the nurse was shirking her responsibility. Feces roll downhill and the OP needs to shovel it back. When I delegate tasks, I am still responsible for supervision, including back-up if the task becomes problematic for the CNA. I can't just issue directives then leave the CNA twisting in the wind.

ETA that the CNA is also responsible for knowing her professional limits and refusing to exceed them.