Failure to Honor Resident's Choice of Physician
Summary
The facility failed to honor a resident's right to choose their attending physician, as evidenced by the case of a resident who expressed dissatisfaction with their current doctor, Dr. F. The resident, who was under contact precautions, reported that Dr. F attempted to examine their PICC line and foot wound without wearing gloves, which led to a confrontation. The resident, who had intact cognition as indicated by a BIMS score of 14/15, explicitly told Dr. F that they no longer wanted them as their doctor. Despite the resident's clear communication of their desire to change doctors, Dr. F intended to see the resident again, assuming the resident might have calmed down. The Director of Nursing confirmed that residents could change doctors at any time and acknowledged that Dr. F should have informed the facility of the resident's decision to terminate their services. The facility's admission contract supports the resident's right to choose their attending physician, yet this right was not initially honored in this instance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident who lacked decision-making capacity had an RP/POA spouse and a physician order requiring that any change in medications, treatments, diagnoses, behaviors, or care plan be approved by the spouse. The RP had arranged for the resident’s psychiatric care through an outside psychiatrist and, during a care conference, verbally and in writing withheld consent for any psychiatric, psychological, or mental health services from the facility’s contracted psychiatrist (PD) or other contracted mental health providers, requesting that they be removed from the resident’s provider list. Despite this, the resident’s profile and face sheet continued to list the contracted PD, the ADON acknowledged the RP’s request but did not remove the PD’s name or notify the PD, and the PD later arrived at the resident’s room with a list that included the resident, prompting the RP to intervene. Surveyors found no evidence that the facility acted on the RP’s request or prevented the PD’s access to the resident’s information, contrary to the facility’s resident rights and privacy policies.
A resident with Alzheimer’s disease, dementia, and type 2 DM was admitted with a POA identified and a long-standing primary care MD documented on a hospital face sheet, but the facility assigned a different attending MD without consulting the resident or POA. The Admissions Coordinator and Director of Marketing each acknowledged they did not speak with the POA or resident about physician choice and did not inform them of the assigned MD, assuming others would handle it. Facility policies on designation of attending physician and resident rights required that residents be asked to choose a personal MD prior to or upon admission and be informed when the facility designates one, but this process was not followed, resulting in the resident being placed under the care of a different MD without the POA’s knowledge or consent.
A resident with DM and ESRD on hemodialysis, who was cognitively intact and required staff assistance with several ADLs, experienced a change in attending physician after the original physician stopped responding to facility and pharmacy calls. The DON reported that the Medical Director assumed care and that the resident was only informed of the change, not involved in selecting the new physician. This process conflicted with facility policies on informed consent and physician services, and failed to honor the resident’s right to choose an attending physician.
Two residents were not given the opportunity to choose their attending physician, as required by regulation. Instead, physicians were assigned from a facility panel without informing the residents or their families of their right to select a provider or how to request an outside physician. Staff interviews revealed a lack of awareness and consistent procedures for facilitating physician choice, and facility policy confirming this right was not followed.
A resident's primary care physician was changed to the facility's Medical Director without notifying the resident or their representative, despite facility policy requiring resident choice and notification. Interviews and record review confirmed that neither verbal nor written notice was provided regarding the change.
A resident with lung cancer and intact cognition was not informed that his chosen physician did not meet facility requirements and was not given the chance to select a new physician while hospitalized. The facility refused to readmit the resident after hospitalization due to concerns about the physician's responsiveness, without notifying the resident or family, and communicated only with the ombudsman. This led to delayed hospital discharge and emotional distress for the resident.
Failure to Honor Resident’s Choice of Psychiatric Provider and RP Authority
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose his attending physician and to follow the directions of the resident’s Responsible Party (RP) and Power of Attorney (POA). The resident, admitted in 2016 with multiple diagnoses including aftercare for cerebral infarction, lacked capacity to make health-care decisions. The clinical record identified the resident’s wife as RP/POA, and a physician order dated 6/12/24 directed staff to call the spouse with any changes to medications, treatments, diets, diagnoses, behaviors, or care plan, and to obtain her approval for any and all changes. The resident’s depression care plan also included an intervention to encourage family to actively participate in the resident’s care. During a care conference in December 2025, the RP told the Social Services Assistant (SSA) that she did not want the resident to be seen by the facility’s contracted psychiatrist (PD) or any other psychiatric provider associated with or contracted by the facility, stating that the resident had been followed by an outside psychiatrist through his medical insurance for years. The RP provided a written letter addressed to the DON, Administrator, and nursing staff withholding consent for consultation or evaluation by any psychiatric, psychological, or mental health practitioner associated with or contracted by the facility and requested that such providers be removed from the resident’s list of care providers. Despite this, the resident’s profile and face sheet continued to list the contracted PD as a provider, and there was no documentation that the facility took steps to accommodate the RP’s request or to notify the PD of the restriction. In March 2026, the RP again raised her concerns with the Assistant DON (ADON), who acknowledged that the RP made all treatment decisions and that the resident was managed by an outside psychiatrist selected by the RP. The ADON told the RP that the PD’s name would be removed from the resident’s profile but admitted she did not do so and did not communicate the RP’s request to the PD. Later that same day, the PD came to the resident’s room with a list of residents to see, which included this resident’s name, and the RP intervened to prevent any evaluation. On review of the record on 3/27/26, surveyors confirmed that the PD’s name remained on the resident’s profile and that the facility’s own Resident Rights policy guaranteed the right to choose a physician and treatment, participate in care planning, and to have privacy and confidentiality, and prohibited unauthorized access or disclosure of resident information.
Failure to Honor Resident’s Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose an attending physician prior to or upon admission, as required by facility policy. The resident was admitted with diagnoses including Alzheimer’s disease, dementia, and type 2 DM, and had moderately impaired cognitive skills for daily decision making, requiring varying levels of assistance with ADLs. The admission record listed a specific physician (MD 3) as the primary physician, while a face sheet faxed from a general acute care hospital identified a different physician (MD 1) as the resident’s primary care physician. The resident’s POA (RP 1) was identified in the admission record, but neither the resident nor RP 1 was asked to choose an attending physician at or before admission. RP 1 reported not being informed that MD 1 was not the attending physician until a change of condition occurred, and stated she was never told the resident would be assigned a new physician or asked about her choice, despite MD 1 having been the resident’s primary physician for over 10 years. The Admissions Coordinator acknowledged assigning the resident to MD 3 without asking RP 1 about physician choice and did not notify RP 1 of the change, stating it was not her responsibility. The Director of Marketing stated that when the referral was received, she assigned the resident to one of the facility doctors without speaking to the resident or RP 1 about their choice of attending physician and did not follow up, assuming another staff member would do so. Review of the facility’s policies on Designation of Attending Physician and Resident’s Rights confirmed that residents must be asked to choose a personal attending physician prior to or upon admission and be informed when the facility designates one, which did not occur in this case, as acknowledged by the Administrator.
Failure to Involve Resident in Choice of Attending Physician
Penalty
Summary
The facility failed to honor a resident's right to choose an attending physician when changing medical providers. A cognitively intact resident with diagnoses including Diabetes Mellitus and ESRD on hemodialysis was admitted with functional limitations requiring varying levels of staff assistance for ADLs such as bathing, dressing, toileting hygiene, and footwear. The resident’s admission record and MDS confirmed intact decision-making abilities. When the initially assigned attending physician stopped responding to calls from facility and pharmacy staff regarding the resident’s care, the facility did not engage the resident in selecting a new physician. Instead, the DON reported that the issue with the non-responsive attending physician was communicated to the Medical Director, who then assumed care of the resident, as reflected in an order summary documenting transfer of care from the first physician to the Medical Director. The DON stated that the resident was informed of the change in physician but was not involved in choosing the replacement provider. This process did not align with the facility’s own policies on Informed Consents and Physician Services, which state that residents have the right to make informed decisions about their care and that physicians are responsible for supervising medical care, including responding when contacted by the facility.
Failure to Ensure Resident Right to Choose Attending Physician
Penalty
Summary
The facility failed to ensure that residents were afforded their right to choose their attending physician, as required by federal and state regulations. For two residents, the facility assigned attending physicians from a pre-selected panel without involving the residents or their families in the decision-making process. In one case, a resident with multiple complex medical conditions, including immunodeficiency, diabetes, hypertension, COPD, and cancer, was admitted under the care of a physician from the facility's panel, despite the resident's family requesting a different physician who had previously cared for the resident for 27 years. The family was informed by the business office that only panel physicians could be selected and was not provided with instructions on how to request an outside physician. Facility staff, including the Director of Business Development, Medical Records Director, and Social Services Director, were unaware of the family's request and did not facilitate the process for credentialing or reactivating the requested physician, who had previously been credentialed at the facility but was no longer active in the system. In another instance, a resident admitted for physical therapy following a hospital stay was assigned an attending physician from the facility's panel without being informed of the right to choose a physician. The resident reported not being involved in the selection process and was unaware that such a choice was available. Interviews with facility staff revealed a lack of consistent procedures for informing residents of their rights regarding physician choice and for processing requests for non-panel physicians. Staff responses indicated that requests for outside physicians would require written statements and credentialing, but there was no evidence that residents or families were guided through this process. A review of the facility's policy confirmed that residents have the right to choose their attending physician and participate in care decisions. However, the facility's practice of assigning physicians from a limited panel, without informing residents of their rights or providing a clear process for requesting outside physicians, resulted in residents not being involved in the selection of their attending physician. This deficiency was identified through interviews, record reviews, and policy examination, demonstrating a failure to uphold residents' rights as outlined in facility policy and regulatory requirements.
Failure to Notify Resident and Representative of Physician Change
Penalty
Summary
The facility failed to honor a resident's right to choose their attending physician by changing the resident's primary care physician without notifying the resident or their representative. According to the facility's Resident Rights Policy, residents are entitled to autonomy and choice regarding their care, including the selection of their physician. The resident was admitted with a specific primary care physician, but the facility switched the resident's physician to the facility's newly hired Medical Director in May 2025. This change was documented in the electronic health record, which showed that the new physician continued to provide care in the following months. Interviews with the resident's family member and representative confirmed that neither was notified, verbally or in writing, about the change in physician. The Assistant Director of Nursing and the Administrator both verified that there was no documentation of notification to the resident or their representative regarding the physician change. The Administrator also stated that the decision to switch all residents to the new Medical Director was made by the facility after the Medical Director was hired.
Failure to Inform Resident of Physician Ineligibility and Denial of Readmission
Penalty
Summary
The facility failed to inform a resident that his chosen physician did not meet the facility's requirements and did not provide the resident with an opportunity to select a new physician while he was hospitalized. The resident, an adult male with a diagnosis of malignant neoplasm of the lung and intact cognition, was initially under the care of the facility's medical director, who terminated the physician-patient relationship due to conflicts with the resident's family. The facility then instructed the resident to identify a new physician or face discharge, and the resident subsequently selected his outpatient physician to oversee his care at the facility. During a subsequent hospitalization, the facility determined that the new physician was not responsive to urgent communications and decided not to readmit the resident upon discharge from the hospital. The facility did not notify the resident or his family of this decision during the hospitalization, nor did they provide written or verbal communication regarding the refusal of readmission. The resident and his family only learned of the refusal through the hospital's case manager, and the facility communicated solely with the ombudsman regarding the situation. Despite the resident's family expressing satisfaction with the new physician and the physician's office confirming ongoing oversight, the facility maintained that the physician did not meet their expectations for responsiveness and refused readmission. The resident's appeal of the discharge was not honored, and the facility did not provide the resident with an opportunity to select another physician prior to the refusal. The lack of communication and failure to allow physician selection led to a delay in the resident's hospital discharge and caused emotional distress.
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