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

VANurse2010 · Jun 21, 2015

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 · Jun 21, 2015

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.

mvm2 · Jun 21, 2015

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 · Jun 21, 2015

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.

allnurses Guide · Jun 22, 2015

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 · Jun 22, 2015

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.

canigraduate · Jun 22, 2015

I have a LTC patient who is verbally abusive and refuses all care when you ask to bathe or change her.

The right to refuse is limited to people in full command of their faculties.

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.

The nurse cannot force you to do anything, as that means physical compulsion. You gave in. Whether it was to coercion or direction is unknown to us. If you are uncomfortable with the way the nurse approached you, it is your responsibility to be assertive, stop the situation, and go up the chain of command.

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. 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.

You have the right to a safe workplace. In this case, you should have stopped immediately. You wrote earlier that she was verbally abusive, but this is physical assault.

You wrote a lot of "she will" rather than "she did." How do you know what she will do if this is your first time caring for her? Have you helped others care for her in a similar situation? Are you just mad at the nurse for not letting you refuse to care for her? Viewing this objectively, I am forced to wonder if this is in reaction to the nurse being firm with you.

I am 9 weeks pregnant and my employer knows that. I cannot be kneed in the stomach.

You do not have the right to refuse work tasks just because you are pregnant. You can refuse if the fetus is at risk for actual harm, such as with shingles or with complicated pregnancies (who usually have been put on light duty by their OBGYN). However, getting kneed in the stomach is not safe, no matter whether you have a full uterus or not.

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?

First, make sure the patient is competent to make her own decisions. Second, see above.

The nurse can command you all she wants and you don't have to do jack squat that compromises your safety. It is within your rights to be safe, but you must attempt to deliver that care and determine that you are NOT safe at that specific time.

You can't unilaterally refuse to provide care for someone in the event that she MIGHT get combative.

You need to educate yourself on what is and is not safe for the fetus. Your "feelings," although strong and valid to you, do not count.

A care conference needs to be held. This behavior is suspicious for abuse. There needs to be an investigation to see if this poor patient is being abused, is having psych issues, or has a cognitive deficit that can be addressed. This is NOT acceptable behavior. Usually residents who act like this have an underlying problem that is CAUSING the behavior, which can be addressed.

A care plan needs to be put in place that keeps both you and the patient safe.

Psych meds used for psych conditions are perfectly appropriate and do not constitute a chemical restraint.

Case in point, I had a patient who was sexually aggressive, combative, and rude. A lot of the nurses thought he was acting that way on purpose and was a jerk. Eventually it was determined that he had a form of schizophrenia and was placed on a cocktail of different drugs. He went from being the absolute worst patient to being the sweetest, kindest man. He continually thanked us, because the world he had been living in, prior to finding the right meds, was a "hell place."

Red Kryptonite · Jun 22, 2015

And managers wonder why floor nurses and aides tend to have bad opinions of them. How dare they let this continue? How dare they expect their staff to get beat up just to do their jobs, while they sit safe and comfortable in an air-conditioned office sipping coffee? Or completely unavailable, safe at home....

jadelpn, LPN, EMT-B · Jun 22, 2015

All of the suggestions from pp are great ones. I would also just like to add that this patient should NOT be a "go in alone and deal" patient. There needs to be 2 or 3 people. Yes, she has the right to refuse if it is determined that she is competent to do so, however, patients can not lay around in their own fluids. And as noted above, a care conference needs to happen with this patient. If she is refusing meds, then a change in medication may not work, either. She may have to have a time in geri psych to address her issues.

In the meanwhile, this should be the patient that the nurse goes in and says "we are having to clean you up, change your clothes, and make you comfortable." And actually assist 2 CNA's with that. There's "restraining" and there's holding ones hands as to not hit/scratch that kind of thing. Another thought process is family members who can help be present to perhaps ease anxieties.

OP, if you are working with another CNA, where is this CNA? I would have discussion with the nurse manager on having a team of 2 CNA's to specifically care for the more difficult patients.

canigraduate · Jun 22, 2015

BTW, the next time a resident harms you, you need to file an incident report. Every single time. That way you have documentation available for the care conference and in the event that you need proof for injury claims.

VANurse2010 · Jun 22, 2015

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

The definition of chemical restraint varies by law. In my state, giving, for example, Haldol 2mg IM to a patient/resident who is getting violent is not considered a restraint - but giving 10mg IM would be.

ComeTogether, LPN · Jun 22, 2015

You need to let the nurse know that you need help with this patient, because its not safe to care for her alone. If she can't help you, another aid needs to.

With confused patients it's neglect if you allow them to refuse certain kinds of care. This is where common sense comes in (I'm not being rude, just being honest) and you have to determine what can be skipped and what needs to be done.

For example, you can't leave her sitting in a soiled brief, but you could wiat on changing her clothes if they aren't soiled until later when shes more calm.

These patients require a special skill set and some serious patience. Maybe start with looking happy to see her, ask her how she is today, etc. I had one lady where If I walked in to her room and acted like she was my long lost cousin she would allow me to care for her. Sometimes you do need to kind of hold her arms out of the way and get another helper to assist you. You should not be doing it alone.