Source anchor
CMS MDS 3.0 RAI Manual v1.20.1 is the governed baseline currently attached to this lookup item.
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MDS Lookup
Rejection of Care—Presence & Frequency
Item Rationale
Matrix review
7 matrix group(s) are already attached for review on this item.
Answer coverage
4 governed answer row(s) are attached for this item.
Answer Codes
Code 0
Behavior not exhibited
if rejection of care consistent with goals was not exhibited in the last 7 days.
Code 1
Behavior of this type occurred 1-3 days
if the resident rejected care consistent with goals 1-3 days during the 7-day look-back period, regardless of the number of episodes that o...
Code 2
Behavior of this type occurred 4-6 days, but less than daily
if the resident rejected care consistent with goals 4-6 days during the 7-day look-back period, regardless of the number of episodes that o...
Code 3
Behavior of this type occurred daily
if the resident rejected care consistent with goals daily in the 7-day look-back period, regardless of the number of episodes that occurred...
What this item is
Item Rationale
When to use it
Use this item when the facility is completing content tied to Section E and needs to stay anchored to v1.20.1.
Reminders
- Current source status: Published.
- Item locator: Manual page E-14
- CMS exact locator: Manual page E-14
- This item has 4 governed answer row(s) attached.
Source awareness
This page is grounded in CMS MDS 3.0 RAI Manual v1.20.1. Review the exact text and locators before treating the item as final reference content.
Source & Review
Manual
CMS MDS 3.0 RAI Manual v1.20.1
Status
Published
Effective start
2025-10-01
Item locator
Manual page E-14
CMS exact locator
Manual page E-14
Full CMS Text
Item Rationale
Health-related Quality of Life
Goals for health and well-being reflect the resident’s wishes and objectives for health, function, and life satisfaction that define an acceptable quality of life for that individual. 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.” It is really a matter of resident choice. When rejection/decline of care is first identified, the team then investigates and determines the rejection/decline of care is really a matter of resident’s choice. Education is provided and the resident’s choices become part of the plan of care. On future assessments, this behavior would not be coded in this item. A resident might reject/decline care because the care conflicts with their preferences and goals. In such cases, care rejection behavior is not considered a problem that warrants treatment to modify or eliminate the behavior. Care rejection may be manifested by verbally declining, statements of refusal, or through physical behaviors that convey aversion to, result in avoidance of, or interfere with the receipt of care. This type of behavior interrupts or interferes with the delivery or receipt of care by disrupting the usual routines or processes by which care is given, or by exceeding the level or intensity of resources that are usually available for the provision of care. A resident’s rejection of care might be caused by an underlying neuropsychiatric, medical, or dental problem. This can interfere with needed care that is consistent with the resident’s preferences or established care goals. In such cases, care rejection behavior may be a problem that requires assessment and intervention.
Planning for Care
Evaluation of rejection of care assists the nursing home in honoring the resident’s care preferences in order to meet their desired health care goals. Follow-up assessment should consider: — whether established care goals clearly reflect the resident’s preferences and goals and — whether alternative approaches could be used to achieve the resident’s care goals. Determine whether a previous discussion identified an objection to the type of care or the way in which the care was provided. If so, determine approaches to accommodate the resident’s preferences.
Steps for Assessment
1. Review the medical record.
2. Interview staff, across all shifts and disciplines, as well as others who had close interactions
with the resident during the 7-day look-back period.
3. Review the record and consult staff to determine whether the rejected care is needed to
achieve the resident’s preferences and goals for health and well-being.
4. Review the medical record to find out whether the care rejection behavior was previously
addressed and documented in discussions or in care planning with the resident, family, or significant other and determined to be an informed choice consistent with the resident’s values, preferences, or goals; or whether that the behavior represents an objection to the way care is provided, but acceptable alternative care and/or approaches to care have been identified and employed.
5. 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 them directly whether the behavior is meant to decline or refuse care.
DEFINITIONS
REJECTION OF CARE Behavior that interrupts or interferes with the delivery or receipt of care. Care rejection may be manifested by verbally declining or statements of refusal or through physical behaviors that convey aversion to or result in avoidance of or interfere with the receipt of care. INTERFERENCE WITH CARE Hindering the delivery or receipt of care by disrupting the usual routines or processes by which care is given, or by exceeding the level or intensity of resources that are usually available for the provision of care. If the resident indicates that the intention is to decline or refuse, then ask them about the reasons for rejecting care and about their goals for health care and well-being. If the resident is unable or unwilling to respond to questions about their rejection of care or goals for health care and well-being, then interview the family or significant other to ascertain the resident’s health care preferences and goals.
Coding Instructions
Code 0, behavior not exhibited: if rejection of care consistent with goals was not
exhibited in the last 7 days.
Code 1, behavior of this type occurred 1-3 days: if the resident rejected care
consistent with goals 1-3 days during the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days.
Code 2, behavior of this type occurred 4-6 days, but less than daily: if
the resident rejected care consistent with goals 4-6 days during the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days.
Code 3, behavior of this type occurred daily: if the resident rejected care
consistent with goals daily in the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days.
Coding Tips and Special Populations
The intent of this item is to identify potential behavioral problems, not situations in which care has been rejected based on a choice that is consistent with the resident’s preferences or goals for health and well-being or a choice made on behalf of the resident by a family member or other proxy decision maker. Do not include behaviors that have already been addressed (e.g., by discussion or care planning with the resident or family) and determined to be consistent with the resident’s values, preferences, or goals. Residents who have made an informed choice about not wanting a particular treatment, procedure, etc., should not be identified as “rejecting care.” Examples
1. A resident with heart failure who recently returned to the nursing home after surgical repair
of a hip fracture is offered physical therapy and declines. They say that they get too short of breath when they try to walk even a short distance, making physical therapy intolerable. They do not expect to walk again and does not want to try. Their physician has discussed this with them and has indicated that their prognosis for regaining ambulatory function is poor.
Coding: E0800 would be coded 0, behavior not exhibited.
Rationale: This resident has communicated that they consider physical therapy to be
both intolerable and futile. The resident discussed this with their physician. Their choice to not accept physical therapy treatment is consistent with their values and goals for health care. Therefore, this would not be coded as rejection of care.
2. A resident informs the staff that they would rather receive care at home, and the next day
they call for a taxi and exits the nursing facility. When staff try to persuade them to return, they firmly state, “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.” They are not exhibiting signs of disorientation, confusion, or psychosis and has never been judged incompetent.
Coding: E0800 would be coded 0, behavior not exhibited.
Rationale: Their departure is consistent with their stated preferences and goals for
health care. Therefore, this is not coded as care rejection.
3. A resident goes to bed at night without changing out of the clothes they wore during the day.
When a nursing assistant offers to help them get undressed, they decline, stating that they prefer to sleep in their clothes tonight. The clothes are wet with urine. This has happened 2 of the past 7 days. The resident was previously fastidious, recently has expressed embarrassment at being incontinent, and has care goals that include maintaining personal hygiene and skin integrity.
Coding: E0800 would be coded 1, behavior of this type occurred 1-3 days.
Rationale: The resident’s care rejection behavior is not consistent with their values and
goals for health and well-being. Therefore, this is classified as care rejection that occurred twice.
4. A resident chooses not to eat supper one day, stating that the food causes them diarrhea. They
say they know they need to eat and do not wish to compromise their nutrition, but they are more distressed by the diarrhea than by the prospect of losing weight.
Coding: E0800 would be coded 1, behavior of this type occurred 1-3 days.
Rationale: Although choosing not to eat is consistent with the resident’s desire to avoid
diarrhea, it is also in conflict with their stated goal to maintain adequate nutrition.
5. A resident is given their antibiotic medication prescribed for treatment of pneumonia and
immediately spits the pills out on the floor. This resident’s assessment indicates that they do not have any swallowing problems. This happened on each of the last 4 days. The resident’s advance directive indicates that they would choose to take antibiotics to treat a potentially life-threatening infection.
Coding: E0800 would be coded 2, behavior of this type occurred 4-6 days,
but less than daily.
Rationale: The behavioral rejection of antibiotics prevents the resident from achieving
their stated goals for health care listed in their advance directives. Therefore, the behavior is coded as care rejection.
6. A resident who recently returned to the nursing home after surgery for a hip fracture is
offered physical therapy and declines. They state that they want to walk again but is afraid of falling. This occurred on 4 days during the look-back period.
Coding: E0800 would be coded 2, behavior of this type occurred 4-6 days.
Rationale: Even though the resident’s health care goal is to regain their ambulatory
status, their fear of falling results in rejection of physical therapy and interferes with their rehabilitation. This would be coded as rejection of care.
7. A resident who previously ate well and prided themself on following a healthy diet has been
refusing to eat every day for the past 2 weeks. They complain that the food is boring and that they feel full after just a few bites. They say they want to eat to maintain their weight and avoid getting sick, but they cannot push themself to eat anymore.
Coding: E0800 would be coded 3, behavior of this type occurred daily.
Rationale: The resident’s choice not to eat is not consistent with their goal of weight
maintenance and health. Choosing not to eat may be related to a medical condition such as a disturbance of taste sensation, gastrointestinal illness, endocrine condition, depressive disorder, or medication side effects.
Matrix Applicability
Nursing Home Subsets
NC - Comprehensive
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NQ - Quarterly
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
ND - Discharge
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NP - PPS 5 Day
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Program and Policy Use
Care Area Triggers
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
PDPM
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Swing Bed Subsets
SP - PPS 5 Day
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
SD - Discharge
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Shared NH/SB Subsets
IPA - Interim Payment
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Stand Alone Assessments
OBRA Admission A=01, B=99, F=99, G=^, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Quarterly A=02, B=99, F=99, G=^, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Annual / Sig Chg A=03, B=99, F=99, G=^, H=0 A= 04, B=99, F=99, G=^, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Discharge A=99, B=99, F=10, 11, G=1, 2, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
D/C Items (Only when A0310F = 10 or 11)
A0310G=1 PDC
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
A0310G=2 UPD
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Item Subset Required Use ISC Skip Patterns
PDPM (A0310B = 01 or 08)
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4