THE FAMILY SAYS, “DON’T SEND THEM TO THE HOSPITAL.” NOW WHAT?
When Your ALF Believes a Resident Needs Medical Evaluation, a Family Objection Doesn’t Make the Facility’s Responsibility Disappear
Your resident has been complaining of significant pain.
Maybe it’s unusual for them. Maybe it’s getting worse. Your staff have been monitoring the resident, and based on what you’re seeing, you believe the resident should be evaluated at the hospital to rule out something serious.
So you call the family.
And they say:
“Don’t send Mom to the hospital.”
Now what?
This can put an ALF administrator in a very uncomfortable position.
You want to respect the resident and work with the family. You don’t want to create unnecessary conflict.
But you also have a responsibility to the resident.
And simply documenting:
“Family didn’t want resident sent out.”
doesn’t necessarily end the facility’s responsibility.
THE FACILITY STILL HAS AN OBLIGATION TO ACT
Florida’s ALF regulations place responsibility on the facility to provide personal supervision and monitor the resident’s health, safety, and well-being.
Under Rule 59A-36.007(1), F.A.C. — Resident Care Standards, personal supervision includes daily observation by designated staff and awareness of the resident’s general health, safety, and physical and emotional well-being.
The rule also addresses what the facility must do when a resident exhibits a significant change.
Official regulation:
https://flrules.org/gateway/ruleno.asp?id=59A-36.007
Florida Statute §429.255 — Use of Personnel; Emergency Care also addresses the responsibilities of ALF personnel. Among other requirements, ALF staff must exercise their professional responsibility to observe residents, document those observations in the resident’s record, and report observations to the resident’s physician.
Official statute:
That’s important.
The facility can’t simply ignore what it is observing because a family member doesn’t want the resident evaluated.
“THE FAMILY SAID NO” DOESN’T AUTOMATICALLY END THE CONVERSATION
Imagine the resident continues complaining of significant pain.
Your staff are concerned.
You believe something could be wrong.
The family says:
“She’s probably fine. Just keep an eye on her.”
Six hours later, the resident’s condition becomes significantly worse.
Now imagine AHCA reviewing the situation afterward.
Or imagine sitting in a deposition and being asked:
“Your staff were concerned enough that they believed the resident needed medical evaluation. What did the facility do?”
Saying:
“We called the daughter and she told us not to send her.”
may lead to a lot more questions.
Was the resident capable of making their own decision?
Who had authority to make healthcare decisions?
Was the healthcare provider contacted?
What symptoms were observed?
What did the physician say?
Did the resident’s condition continue to change?
What did the facility document?
Those are the questions administrators should be thinking about.
CALL THE HEALTHCARE PROVIDER
This is where facilities can often avoid unnecessary conflict.
If the situation allows, contact the resident’s primary healthcare provider.
Explain what you’re observing.
Document the communication.
Ask for direction.
If the physician agrees that the resident should be evaluated, that can also help with the family conversation.
Instead of the administrator arguing:
“I think she needs to go.”
you may now be able to say:
“We contacted her healthcare provider, explained what we’re seeing, and the provider also recommends that she be evaluated.”
If possible, have the provider speak directly with the family.
Sometimes hearing the same recommendation from the resident’s physician changes the entire conversation.
And Florida law specifically addresses ALF staff reporting their observations to the resident’s physician.
DO YOUR BEST TO GET EVERYONE ON THE SAME PAGE
The goal shouldn’t be to fight with the family.
Explain your position.
You might say:
“I understand that you don’t want your mother going to the hospital unnecessarily. We don’t want that either. But she’s experiencing something outside of her normal condition, and we’re concerned. We don’t have the ability in the ALF to rule out what may be causing this. We believe she needs additional medical evaluation.”
That conversation is very different from:
“We’re sending her whether you like it or not.”
Work with the family.
Contact the healthcare provider when the circumstances allow.
Explain your concerns.
But don’t allow the desire to avoid an uncomfortable conversation to prevent the facility from responding appropriately to a resident’s condition.
REMEMBER WHO THE DECISION-MAKER IS
Another important question is:
Who actually has the authority to make the healthcare decision?
Don’t automatically assume that the family member listed as the emergency contact can override the resident.
If the resident is capable of making their own healthcare decisions, the resident’s wishes matter.
If someone else is making healthcare decisions for the resident, determine what legal authority that person has and what applicable advance directives or other documentation exist.
That’s another reason these documents should be reviewed before a difficult situation occurs.
WHEN IN DOUBT, SEND THEM OUT
I’ve said this for years:
WHEN IN DOUBT, SEND THEM OUT.
That’s not the wording of the Florida regulation.
It’s a practical risk-management principle.
If a resident is experiencing a concerning change and your facility cannot determine what’s happening within the scope of an ALF, don’t allow fear of upsetting the family to become the reason you fail to act.
There’s a big difference between unnecessarily sending every resident to the emergency room and recognizing when something is outside your facility’s ability to safely evaluate.
You can explain your decision to an angry family.
You can work with the physician to reduce unnecessary hospital visits going forward.
But what is much harder to explain is why everyone knew something was wrong and nobody took appropriate action.
DOCUMENT THE ENTIRE PROCESS
Don’t document only:
“Family notified.”
Tell the story.
Document:
- What the resident complained about.
- What staff observed.
- When the concern began.
- Whether the resident’s condition changed.
- Who was notified and when.
- When the healthcare provider was contacted.
- What information was provided.
- What instructions or recommendations were received.
- What the family said.
- What the resident said, when applicable.
- What action the facility ultimately took.
Your documentation should allow someone reviewing the record months later to understand what happened and why the facility made the decision it made.
HOW TO STAY COMPLIANT
When a resident experiences a concerning change:
- Observe the resident and document what you’re seeing.
- Follow your facility’s notification procedures.
- Notify the healthcare provider as required.
- Notify the appropriate resident representative as required.
- Don’t assume an emergency contact automatically has healthcare decision-making authority.
- Understand the resident’s advance directives and authorized decision-maker, when applicable.
- Follow healthcare-provider instructions within the facility’s scope and license.
- If the resident needs medical evaluation beyond what the ALF can provide, take appropriate action.
- Document the family conversation and the facility’s response.
And most importantly:
DON’T LET FEAR OF MAKING THE FAMILY ANGRY KEEP YOU FROM PROTECTING THE RESIDENT.
THE BOTTOM LINE
The family may tell you:
“Don’t send Mom to the hospital.”
Listen to them.
Explain your concerns.
Get the healthcare provider involved when possible.
Try to get everyone on the same page.
But remember:
The facility still has responsibilities of its own.
Your staff observed the resident.
Your facility identified the concern.
Your facility has an obligation to respond appropriately.
And if something serious happens later, “the family told us not to” may not answer the question of whether the facility fulfilled its responsibilities.
Sometimes making the right decision will make a family unhappy.
That’s part of operating an assisted living facility.
WHEN IN DOUBT, SEND THEM OUT.
Not because the regulation literally says those words.
It doesn’t.
It’s because when you’re faced with a potentially serious medical concern that your ALF cannot evaluate, resident safety has to come first.
OFFICIAL RESOURCES
Rule 59A-36.007, F.A.C. — Resident Care Standards
https://flrules.org/gateway/ruleno.asp?id=59A-36.007
Florida Statute §429.255 — Use of Personnel; Emergency Care
https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499%2F0429%2FSections%2F0429.255.html