Failure to Inform Resident and Responsible Party of Right to Choose Attending Physician
Penalty
Summary
The facility failed to ensure that a resident and their responsible party were informed of the right to choose or change the attending physician. Upon admission, the resident, who had diagnoses including cerebral palsy, altered mental status, and quadriplegia, was not provided with documentation or evidence that the right to select an attending physician was discussed with either the resident or their responsible party. The resident's medical records indicated a lack of cognitive capacity to make decisions, and the Minimum Data Set confirmed total dependence on staff for activities of daily living. Interviews with facility staff, including the Social Services Director and the Director of Nursing, revealed that while the facility has a process for informing residents of their rights, including the right to change physicians, there was no documentation that this process was followed for this particular resident. The Social Services Director was not employed at the time of the resident's admission, and the Director of Nursing confirmed that there was no record of any discussion or documentation regarding the choice of attending physician for the resident or their responsible party. A review of the facility's policy on the choice of attending physician confirmed that residents have the right to choose their own physician and that the facility should not interfere with this process. However, the lack of documentation and failure to inform the resident or responsible party of this right resulted in the resident and their responsible party not being made aware of the option to select or change the attending physician, as required by federal regulations.
Plan Of Correction
F 555 RIGHT TO CHOOSE/BE INFORMED ATTENDING PHYSICIAN CFR(s): 483.10(d)(1)-(5) IMMEDIATE CORRECTIVE ACTION: Resident 1 was discharged on 1/3/21. ACTION TAKEN TO IDENTIFY ALL OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE AND CORRECTIVE ACTION TAKEN: All residents had the potential to be affected by this deficient practice. The Social Services Director and Designee interviewed 10 newly admitted residents in the last two (2) weeks to determine if they were aware of their rights to choose an attending physician and if they needed assistance with changing their attending physician. No other residents were found to be affected by this deficient practice. PROCESS AND ACTION TAKEN TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR: The Director of Nursing Services (DON) conducted an in-service education with the licensed staff on 6/30/25, regarding facility policy and procedure on Change of Physician, ensuring that residents are aware of their rights and assistance is available when they request a change of physician. The Administrator conducted an in-service with Social Services department staff on 7/7/25, regarding facility policy on Choice of Attending Physician focusing on the right of the resident to choose his or her own attending physician. Effective 7/7/25, the Activity Director will review residents' rights to include the right to choose an attending physician during the monthly Resident Council meeting for the next three months and quarterly thereafter. If the resident subsequently chooses another attending physician who meets the requirements and responsibilities of an attending physician, the facility will honor that choice. ACTION TAKEN TO IDENTIFY ALL OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE AND CORRECTIVE ACTION TAKEN: All residents had the potential to be affected by this deficient practice. The Social Services Director and Designee interviewed 10 newly admitted residents in the last two (2) weeks to determine if they were aware of their rights to choose an attending physician and if they needed assistance with changing their attending physician. No other residents were found to be affected by this deficient practice. PROCESS AND ACTION TAKEN TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR: The Director of Nursing Services (DON) conducted an in-service education with the licensed staff on 6/30/25, regarding facility policy and procedure on Change of Physician, ensuring that residents are aware of their rights and assistance is available when they request a change of physician. The Administrator conducted an in-service with Social Services department staff on 7/7/25, regarding facility policy on Choice of Attending Physician focusing on the right of the resident to choose his or her own attending physician. Effective 7/7/25, the Activity Director will review residents' rights to include the right to choose an attending physician during the monthly Resident Council meeting for the next three months and quarterly thereafter. If the resident subsequently chooses another attending physician who meets the requirements and responsibilities of an attending physician, the facility will honor that choice. Effective 7/7/25, the Social Service Director or the Social Services Designee will notify the resident and/or resident's RP during the Interdisciplinary Team (IDT) meeting of their right to choose a physician and assist them as needed. If the resident subsequently chooses another attending physician who meets the requirements and responsibilities of an attending physician, the facility will honor that choice. The DON and/or her designee will conduct a random review of five (5) residents or residents' RP weekly for the next 30 days to ensure that they are aware of their rights to choose an attending physician and that assistance is provided if they need to change physicians. MONITORING PERFORMANCE TO ENSURE THAT CORRECTION IS ACHIEVED AND SUSTAINED: As part of the facility's Continuous Quality Improvement (CQI) program, the DON and/or her designee will report findings of the weekly random reviews to the Quality Assessment and Assurance Committee (QAA) at the next monthly meeting. The DSS will also report her daily findings at the next monthly QAA meeting. The Administrator will monitor compliance through review of the DON's report. CORRECTIVE ACTION COMPLETION: July 7, 2025