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Is it rejection of care or resident choice?

February 12, 2014
by Judi Kulus, NHA, RN, MAT, RAC-MT, C-NE
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Mrs. Smith, a resident at Sleepy Acres Nursing Home, had severe dementia. She could not voice her wishes and preferences and was dependent on staff for her activities of daily living. Her assigned nursing assistant had a hard time getting her ready for breakfast in the morning because she would “fight” being moved in bed, cleansed and changed. As a result of Mrs. Smith’s yelling “no” and attempting to hit the nursing assistant to avoid receiving care, three nursing assistants decided to meet in Mrs. Smith’s room one morning at 6:30 to provide her care together. With some difficulty, they were able to safely accomplish cleansing, dressing and moving Mrs. Smith into her wheelchair so that she could be taken to the dining room for breakfast around 8:00.

The MDS nurse was tasked with coding her Minimum Data Set (MDS) Quarterly assessment, item E0800, Rejection of Care. While reviewing this item, the nurse considered whether Mrs. Smith’s actions were rejection of care or whether, instead, her values, preferences or goals were being violated. She pored over the medical record and came across the social history, where she discovered that Mrs. Smith had been a nurse for 40 years, working the night shift. Mrs. Smith’s daughter was noted in the record to have commented that her mom was never a morning person and was accustomed to sleeping in until nearly noon. She would eat very little until after lunch.

Even though Mrs. Smith could not communicate her values, preferences and goals, she was expressing them through her resistance to morning cares. The staff decided to schedule her care last instead of first and let her sleep in. Shortly after this change in schedule, her “behaviors” stopped and she allowed her nursing assistant to assist her with cares. The MDS was not coded as “rejection of care” since Mrs. Smith’s refusal to get up in the morning was in line with her preferences and lifestyle.

MDS item E0800, Rejection of Care, can be a difficult item for facility staff to code correctly, particularly when a cognitively impaired resident cannot or does not voice her desires. When faced with a particular behavior or refusal to participate in established care-planning interventions, staff must evaluate whether this is truly rejection of care or is it perhaps the resident’s choice.

The RAI User’s Manual1 defines rejection of care as “behavior that interrupts or interferes with the delivery or receipt of care” (CMS 2013, chap. 3, p. E-14). This care rejection could be manifested in verbal declines or through physical behaviors showing aversion to the care provided. Staff should never assume that a cognitively impaired resident’s behavior is automatically a rejection of care.

Clinicians should ask the family or significant other to explain what he or she sees as the resident’s lifelong values, preferences and goals. Rejection of care is not based on what the facility staff have established as their own goals for the resident; rather, they should seek to ascertain what the resident’s goals are for his or her own well-being, health, functional status and life satisfaction. These items help define an acceptable quality of life for each individual resident (p. E-13).

Consider a resident who spent his entire life being fastidious about his cleanliness and attire, and who expresses embarrassment at being incontinent. However, on two occasions during the MDS look-back period he declined to allow the nursing assistant to assist him to change and be cleansed and instead chose to sleep in his wet clothing. Since the refusal for assistance is not consistent with his values and goals for health and well-being, it would be considered rejection of care (p. E-16).

During the completion of an MDS assessment, facility staff have an opportunity to evaluate how well they are honoring a resident’s care preferences regardless of that resident’s ability to voice those preferences. Sometimes this is difficult to do, especially when a resident has conflicting goals. For example, a resident refused to eat supper because she was afraid that it would cause diarrhea. She rejected supper even though she said she knew she needed to eat and did not want to compromise her nutrition. This would be considered rejection of care even though refusing to eat in order to avoid diarrhea is a choice she could make, it is in conflict with her goal of maintaining her nutritional status (p. E-16).

When it is determined by the facility team that a particular “behavior” is an expression of the resident’s preferences, it is not to be coded as rejection of care. Alternative interventions need to be explored. However, if a resident’s refusal of care interventions prevents her self-goals from being met, it should be considered rejection of care in E0800.

In the MDS coding world, there is some confusion about continuing to code rejection of care once it has been care-planned. The RAI manual instructions indicate that as long as a behavior is considered a rejection of the resident’s own goals for him- or herself, the behavior should continue to be coded as rejection of care on subsequent MDS assessments, even if it has been thoroughly addressed in the care plan.

Judi Kulus, NHA, RN, MAT, RAC-MT, C-NE, is Vice President of Curriculum Development for the American Association of Nurse Assessment Coordination (AANAC). To contact her, email