California Nursing Home Administrator License Practice Exam

What documentation is essential if a resident refuses care related to a therapeutic diet?

1. Require a consultation with a dietician

2. Must be recorded in the major incident log

3. Documentation must be noted in the resident record

4. No documentation is necessary

The correct answer is: Documentation must be noted in the resident record

When a resident refuses care related to a therapeutic diet, it is crucial to document this refusal in the resident's record. Proper documentation serves several important purposes. First, it ensures that there is a clear, legal record of the resident's decisions concerning their health care and dietary needs. This documentation helps protect the nursing home from liability by demonstrating that the facility made efforts to provide appropriate care and that the resident was informed and voluntarily refused it. Additionally, noting the refusal in the resident's record may help other healthcare staff understand the resident's choices and preferences, guiding future care plans. It allows staff to monitor the resident's health and well-being effectively and to engage in conversations about the therapeutic diet, reassuring the resident of its benefits and addressing any concerns they may have. In contrast, requiring a consultation with a dietician may be a part of the process regarding diet-related issues, but it does not replace the need for documentation. Recording the incident in the major incident log may be necessary for significant events or complications, but a simple refusal does not typically qualify as such. Lastly, no documentation being necessary is not appropriate since it could lead to misunderstandings and potential legal issues. Therefore, documenting the refusal in the resident record is the correct and most essential action.