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Unmasked Patients: Conflicts, Accommodations and Common Sense

The challenges brought on by COVID-19 can also include navigating interactions with patients who simply refuse to wear face masks. Learn how to make safe accommodations for patients who have medical concerns. And, for those who refuse masks on just philosophical bases, learn how to communicate effectively, reduce conflict and preserve staff safety.

Even before COVID-19 inexorably changed social and clinical protocols, dental offices dealt with patients who claimed to “know better” than their providers when it came to health risks. From unvaccinated patients to incomplete health histories, failure to cooperate results in ethical and legal challenges for dentists. In today’s practice environment, these challenges also include navigating interactions with patients who simply refuse to wear face masks.

Dentists and their team members are put in uncomfortable positions when this occurs. For a patient who truly has a medical or psychological concern, how can the practice make safe accommodations? For patients who refuse to wear a mask on a philosophical basis, how can the practice communicate effectively, reduce conflict and preserve staff safety?

Regardless of patients’ needs or just “knowing better,” start with plain-speak communication about the practice’s expectations.

Notify patients of increased safety protocols in advance of their appointments. Patients should understand what to expect: mandatory masks, temperature checks, oxygen saturation readings, hand sanitization, screening questions, guest limitations or reception room restrictions. Share safety protocols and COVID-19 policies through appointment reminder emails, text messages and phone calls as well as through the practice website and social media pages. Providing early notice allows patients to cancel or reschedule if they aren’t comfortable complying with the safety guidelines. Reinforce the policies again by displaying signage on the office’s front door and at the front desk to be specific, clear and conspicuous to patients upon their arrival.

Mask-exemption accommodations

The Centers for Disease Control and Prevention offers guidance on individuals who could be exempt from wearing a face covering. These exemptions are generally rare and include children under age 2 years and people of any age with certain disabilities or sensory, cognitive or behavioral disorders. Unfortunately, fraudulent “face-mask exemption” cards are circulating in the public, but there is no legitimate boilerplate letter or blanket exception. If a patient requests an accommodation for a disability that is not obvious, providers are permitted to request medical documentation that’s personalized to the individual patient’s condition. If the patient’s disability is apparent, additional information should only be requested if necessary.

Reasonable accommodations for patients with legitimate conditions may include:

  • Offering a teledentistry appointment to determine a treatment plan and then scheduling an in-office appointment time that reduces risks while accommodating needs.
  • Asking a patient to wait in the car or an area away from others until treatment time.
  • Scheduling the patient as the last one seen at the end of the day.
  • Allowing a patient to wear a loose face covering or face shield instead of a mask.

Responding to mask refusal

Even with early and direct communications about practice protocols, some patients will come to their appointments still refusing to comply. Being prepared for difficult conversations and using tactics to de-escalate tension are key to reducing potential liabilities.

Start by training employees on how to handle uncooperative patients. A united front demonstrates to the dental team that they are supported and that their safety is valued. As part of regular conflict resolution training, develop a specific plan on how to respond to patients who refuse to follow safety policies. This may include:

  • Recognizing indicators of possible noncompliance before the appointment, such as hesitation during a reminder call or overly specific questions about mask enforcement.
  • Addressing the unmasked patient outside the practice door or in the doorway, if possible, to avoid allowing the patient to enter common areas as the conversation continues.
  • Offering the patient the option to wear a disposable mask provided by the practice, rescheduling the appointment when they are willing to comply or scheduling a telehealth consultation.
  • Assessing the situation for signs of escalation and feeling comfortable asking practice leadership to intervene.
  • Documenting a clear chain of command and designating a specific team member, such as the office manager, to respond quickly in noncompliance situations and steer toward the best solution.
  • Establishing a tactical approach to dealing with patient aggression or potential violence (threats, verbal assault or physical assault), such as exiting to a safe area of the practice or calling security or an emergency number.
  • Updating workplace violence policies in the employee handbook to cover patient-violence scenarios and the procedure for reporting them.

See additional guidance from the CDC on limiting workplace violence associated with COVID-19 prevention policies.

Staff can encourage patients to comply with practice protocols, but they are not expected to enforce them — especially without proper support or when facing hostility or safety risks. If an employee believes they are not supported in responding to uncooperative patients, the employee might be prompted to leave the practice and possibly file a hostile work environment claim. By documenting violence policies and following through on those policies in support of employees’ mental and physical well-being, practice owners may mitigate liabilities and improve the team’s confidence in working in a challenging climate.

In the event a patient refuses to follow practice protocols, the health and safety of the work environment is compromised for employees and other patients. Assuming there is no other protected classification in which the patient falls and the practice gives adequate notice and an opportunity to find other care, noncompliant patients may be dismissed. Dentists must also remain available for emergency treatment (for a minimum of 30 days) until the patient finds care through another practitioner. To reduce the potential for patient-abandonment claims, contact your professional liability carrier for advice, especially if the patient is midtreatment. Consult your dental society and state occupational safety division for additional regulations or considerations specific to your region.

Balancing obligations to the dental team and all patients can be a challenge, but expert guidance is available through your state dental association and The Dentists Insurance Company. If you are facing concerns about potential claims stemming from patient or employee situations, call TDIC’s Risk Management Advice Line and speak with an experienced analyst.

TDIC’s Risk Management Advice Line is a benefit to TDIC policyholders. To schedule a consultation with an experienced risk management analyst, visit tdicinsurance.com/RMconsult or call 800.733.0633. For Risk Management guidance in Idaho, Oregon or Washington, call 800.452.0504.

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