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Recognizing Rejection of Care: MDS Coding Accuracy for E0800

Rejection of care can occur in many ways—Mr. Jones refuses to have his nails trimmed; Mrs. Abrahams clenches her mouth, refusing to take medications in the evening; or Mr. Martin discharges against medical advice. However, not all of these instances may be coded as rejection of care on the MDS. The key difference is whether or not the resident’s actions are in line with their goals for health and well-being. To make this determination, the assessor must review the care that was refused and how the care plan addresses this situation. However, there are two common misunderstandings regarding this process:

Misunderstanding #1: Once the refusal is care planned, it is never coded as rejection of care again.

A common misunderstanding asserts that once a refusal has been addressed or care planned, it cannot be coded as rejection of care on subsequent assessments. However, this is only true if the rejection is because the care conflicts with the resident’s own preferences for care.

To understand when rejection of care is coded, start by reviewing the full assessment question and instructions on page E-13 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual: “Did the resident reject evaluation or care that is necessary to achieve the resident’s goals for health and well-being? Do not include behaviors that have already been addressed and determined to be consistent with resident values, preferences, or goals.”

The key distinction is whether the addressed behavior was consistent with the resident’s goals and preferences. If a behavior continues which is not consistent with the resident’s goals and preferences, then it is still considered a refusal, even if it was addressed in the care plan or captured on a previous assessment.

Example 1: Mrs. Abrahams clenches her mouth, refusing to take medications in the evening two or more times each week. Mrs. Abrahams has a diagnosis of dementia, and her daughter serves as her representative due to moderate cognitive impairment. On the last assessment, it was noted that Mrs. Abrahams refused Namenda and Tylenol. This behavior was discussed with her representative, and she states that her goals were to minimize effects of the dementia and that she would not want to experience any pain. Refusal of the medications is not in line with her goals and preferences for health and well-being. This behavior continued and occurred during the look-back period of the current assessment. Since the team needs to continue to implement ways to encourage medication administration and reduce the occurrence of refusals, the behavior will still be coded on this MDS assessment at E0800.

Example 2: Mr. Jones refuses to have his nails trimmed. When the assessor discussed this refusal with him, he stated it is difficult to pick up items when his nails are trimmed too short. Mr. Jones stated he will allow staff to clean his nails as needed, but only allow trimming per his request and to the length he requests. After this discussion, it was clear that this behavior is not a refusal because having longer nails is in line with his goals and preferences. The refusal of nail trimming would not be coded on this assessment nor subsequent assessments. The team will need to document Mr. Jones’ preferences for nail care on his personal hygiene care plan to ensure his preferences for care are followed.

Misunderstanding #2: Staff do not have to agree with the reason for refusal.

Another common mistake occurs when the facility staff do not agree with the resident’s values, preferences, or goals for their health and well-being. Page E-13 of the RAI User’s Manual clarifies:

The resident’s care preferences reflect desires, wishes, inclinations, or choices for care. Preferences do not have to appear logical or rational to the clinician. Similarly, preferences are not necessarily informed by facts or scientific knowledge and may not be consistent with “good judgment.”

A key step in the determination of rejection of care is to eliminate personal preference or the assessor’s own goals for the resident’s care. Instead, focus on the resident’s preferences and goals. The RAI User’s Manual also states on page E-13, “A resident might reject/decline care because the care conflicts with his or her preferences and goals. In such cases, care rejection behavior is not considered a problem that warrants treatment to modify or eliminate the behavior.”

Example 3 (Adapted from RAI User’s Manual, p. E-16): Mr. Martin informs the staff that he would rather receive care at home, and the next day he calls for a taxi and exits the nursing facility. When staff try to persuade him to return, he firmly states, “Leave me alone. I always swore I’d never go to a nursing home. I’ll get by with my visiting nurse service at home again.” He is not exhibiting signs of disorientation, confusion, or psychosis and has never been judged incompetent. Rejection of care would not be coded. Mr. Martin stated that his preferences and goals for health and well-being did not include care at the nursing home. While his physician and the nursing home staff may not agree with this decision, discharging from the nursing home was in line with his own goals and preferences for care and is not considered rejection of care.

When you are not sure, ask.

When a behavior occurs and you are not sure whether it should be considered a rejection of care, if it has not been previously documented or care planned, ask the resident directly. This is the fifth step in the Steps for Assessment on page E-14 of the RAI User’s Manual:

If the resident exhibits behavior that appears to communicate a rejection of care (and that rejection behavior has not been previously determined to be consistent with the resident’s values or goals), ask him or her directly whether the behavior is meant to decline or refuse care.

Once you have documented the resident’s response, this will indicate whether or not the behavior should be coded at E0800, Rejection of Care.

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