Two Refused Baths and a Red Mark

You respect the refusal and negotiate, and you tell the daughter plainly that you will not force him.

How to proceed:

• Find the reason. Refusing care twice is usually about something - pain when rolling, embarrassment, fear of being cold, modesty in front of staff, or a bad experience. Ask, and ask privately.
• Break the task down. A full bed bath is a big ask. Offer a partial bath, a warm washcloth to the face and hands, a change of the soiled brief and linen, and perineal care - the parts that cannot wait. Often the resident who refuses a bath will accept a "freshen up."
• Give control. Let him hold the washcloth, choose the water temperature, decide the order, and have a towel over him throughout. Close the door and the curtain.
• Answer the daughter honestly: "I can't force him - that would be restraining him, and he's allowed to say no. What I can do is keep him clean and dry, offer again later, and let his nurse know he's refusing." Then redirect her to encourage him rather than instruct you.

Reasoning: forcing care on a competent adult is a rights violation and a restraint. The directive from a family member does not change the resident's right to refuse.

Non-blanching redness over a bony prominence is a pressure injury until proven otherwise - the redness indicates that tissue damage has already begun, so this is not a cosmetic finding and not something to "watch for a while."

Immediate actions:

1. Take pressure off it. Reposition him off his back - side-lying or tilted - and use pillows to keep the bony area free. Turn and reposition on a schedule, not when you happen to be in the room.
2. Keep it clean and dry. With a catheter and two stool episodes today, moisture and bacteria are the main enemies. Do perineal care after each incontinence episode, change wet or soiled linen immediately, and use a barrier product if the nurse approves.
3. Do not rub or massage the area. Massaging reddened skin over a bony prominence can cause more damage.
4. Do not apply anything on your own - no powders, ointments, or dressings without the nurse.
5. Report it now, with specifics: location (sacrum/tailbone), size (about palm-sized), that it does not blanch, that he winces when rolled, and that he has had two stool episodes and refused baths two evenings.

Reasoning: the wincing matters. Pain on repositioning suggests deeper involvement than a surface mark, and it should be reported in the same breath as the color change.

Chart what you observed, what you did, and what you reported. Leave out conclusions and blame.

Chart:

• "Palm-sized area of redness over sacrum, does not blanch with pressure. Resident winces when repositioned onto side. Repositioned off sacrum, pillows in place. Nurse notified at ___ (time)."
• Incontinence care given, times, and that linen was changed.
• That he declined a bed bath two evenings, and what was offered instead (partial bath, perineal care) and what he accepted.
• That the daughter was informed you cannot force care and was encouraged to support him.

Leave out:

• "Resident has a pressure ulcer." You are not diagnosing. Non-blanching redness is what you saw; staging is the nurse's call.
• "Daughter was demanding and unreasonable." Describe requests as requests.
• "Refused care - noncompliant." State the refusal and what you did about it. "Noncompliant" is a judgment that sticks to the resident and invites worse care from the next shift.

Complete an incident report only if your facility's policy treats an acquired skin injury as a reportable incident; regardless, the chart entry is the permanent record and the handoff to the nurse is what triggers the wound assessment.