Refusal of Care, Grievances, and the Montana Ombudsman

The Right to Refuse Care

A competent adult's most fundamental right is control over their own body. Under 42 CFR 483.10, every resident has the right to refuse care and treatment — a bath, a meal, a medication, a therapy session, or an entire care plan. Refusal is not a behavior problem, and it is not a personal rejection of the CNA.

When a resident refuses, the CNA's response has three parts:

1. Respect the refusal. Stop the task. Never force, trick, restrain, or hold a resident down to complete care. Forcing care on a refusing, competent resident can constitute battery.
2. Do not argue, scold, or bargain. Phrases like "You'll feel better after" or "Your daughter wants you to" pressure the resident and violate their right to choose. You may calmly explain the purpose of the care once ("This position change helps protect your skin") — the resident may then agree — but the decision remains theirs.
3. Inform the nurse. Report the refusal promptly. The nurse assesses why the resident refused (pain? fear? a wish for a different time or caregiver?), documents it, and adjusts the care plan. Repeated refusals may signal a problem the team needs to address.

The CNA also documents or reports exactly what was refused, using the resident's own words where possible — not a judgment like "resident was difficult."

Grievances and Freedom from Retaliation

Residents have the right to voice grievances — complaints about care, treatment, staff, food, roommates, or lost property — and to have the facility respond promptly and try to resolve them, without fear of punishment. Retaliation is prohibited: a resident cannot be discharged, transferred, threatened, ignored, or given poorer care because they complained. Family members and legal representatives may also file grievances on a resident's behalf.

The CNA's role is to take every complaint seriously and report it to the nurse, never to dismiss it ("Nobody else complains about the food") or cover for a coworker. A resident who says "I'm going to complain about this place" is exercising a right, not making a threat.

Every facility must have a written grievance procedure and must inform residents how to use it, including how to contact the state survey agency — in Montana, the DPHHS Quality Assurance Division — if the facility's response does not resolve the problem. Complaints may be made anonymously, and a resident can never be required to raise the concern with a particular staff member first.

The Montana Long-Term Care Ombudsman Program

An ombudsman is an independent advocate for residents. The Montana Long-Term Care Ombudsman Program, operated through the Montana Department of Public Health and Human Services (DPHHS) Senior and Long-Term Care Division with local ombudsmen across the state, serves residents of nursing facilities and assisted living facilities. The word itself comes from Swedish and means, roughly, "representative."

What ombudsmen do:

• Investigate and work to resolve complaints made by or on behalf of residents — about care, rights violations, discharge, food, finances, or staffing
• Act only at the resident's request and direction — the resident controls what the ombudsman does and who is told
• Provide information about resident rights and help residents and families navigate the system
• Advocate for changes to improve quality of care and quality of life
• Services are free and confidential

Facilities must give residents access to the ombudsman and post the program's contact information. A CNA should never block a resident from speaking privately with an ombudsman, and a resident's contact with the ombudsman must never result in retaliation.

Access to Visitors, Mail, and Private Communication

Because the facility is the resident's home, residents retain the rights of any person in their own home:

• Visitors: residents may receive visitors of their choosing, at reasonable times, in private — including family, friends, clergy, physicians, and the ombudsman. A resident may also refuse visitors.
• Mail: mail must be delivered unopened. Staff never open, read, or withhold a resident's mail. The resident may send mail unopened as well.
• Telephone: residents have reasonable access to a phone for private conversations.
• Private communication generally: married residents may share a room if both consent, and residents may meet privately with anyone they choose.

Voting and Religious Rights

Residents keep every right of citizenship. They may vote (facilities assist with registration, absentee ballots, and transportation), practice their religion or choose none, attend services, receive clergy visits, and observe dietary and dress practices of their faith. Staff must never mock, pressure, or interfere with a resident's beliefs — and must never impose their own beliefs on residents. A CNA supports these rights practically: helping a resident dress for a service, reporting a request for clergy, or passing along a request for an absentee ballot.