Failure to Inform Resident of Physician Ineligibility and Denial of Readmission
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Allow Residents to Choose Their Attending Physician: A facility changed the attending physician team without giving residents a choice, despite admission paperwork stating residents may select their own doctor and other providers. Multiple residents said they were not asked, did not receive a list or notice, did not know the new MD, and wanted to remain with their prior physicians; a social worker and the NHA confirmed residents were not given a choice because only one physician was coming into the building.
A facility failed to honor residents’ rights to choose their AP for five residents. Two residents had records showing Physician 1 as their AP, but the facility assigned the MD instead, and both residents/family said they were not allowed to keep Physician 1. Three other residents, each documented as having capacity to make decisions, said they were never asked if they wanted to keep their own AP and were simply assigned the facility MD. The AD stated it was standard practice to assign the MD unless an outside physician would follow the resident, while the DON acknowledged residents should be given the option to choose their AP.
Failure to Honor Resident Choice of Attending Physician: A resident with a fractured elbow said she was assigned the facility physician instead of being offered a choice of attending MD, despite wanting her own MD who knew her meds and pain needs and with whom she felt comfortable due to prior trauma. Staff gave inconsistent accounts of physician assignment, with one stating residents were only allowed to choose MDs already affiliated with the facility or local hospital group, while the facility policy stated residents may choose their attending physician.
Residents Not Offered Choice of Attending Physician: Four residents, including individuals who were alert and oriented or had capacity to make decisions, stated they were assigned an attending physician on admission and were not asked whether they wanted to retain a personal physician or choose one of their own. The AM, AD, and DON confirmed residents were assigned physicians from an approved panel and were not offered a choice upon admission, despite the facility's Resident Rights policy stating residents have the right to choose an attending physician.
Failure to Provide Physician Choice Form: A resident with stroke, dementia, dysphagia, DM2, and bipolar disorder was found to lack decision-making capacity and have severely impaired cognition. The RP emailed the administrator requesting that the resident’s PCP continue as the attending physician, but the ADON confirmed the RP was not given the facility’s Resident’s Right to Choose a Physician form. The ADON stated residents have the right to choose their physician and that staff should have helped contact the requested physician.
A resident’s right to choose an attending physician was not honored when the facility changed the resident’s PCP from Physician A to Physician B after discontinuing services with Physician A. The resident was cognitively intact and stated he/she wanted to stay with Physician A but did not have a choice. Social services documented the PCP change and later asked if the resident wanted to return to Physician A when that physician resumed practice at the facility.
Failure to Allow Residents to Choose Their Attending Physician
Penalty
Summary
The facility failed to honor residents’ right to choose their attending physician when it changed the attending physician team without allowing residents to select their own doctor. The admission packet stated that residents may select their own doctor and other health care providers, but the survey findings showed that this did not occur for 13 of 14 residents interviewed about the change, including Residents #2, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #21, and #24. Surveyors reviewed complaints alleging that the facility changed the attending physician team without giving residents a choice. During interview, the social worker stated that a letter from the NHA about the physician change was given to residents, or to representatives if the resident had a low BIMS, and that no further paperwork was provided. The social worker also stated that there was only one attending physician in the facility at that time and that residents really did not have a choice because only one doctor was in the building. Multiple residents stated they were not asked for permission, were not given a list of physicians, did not receive a letter to choose a new doctor, and did not know the name of the new physician. Several residents said they wanted to remain with their prior physicians, including physicians they had known for years or who knew their medical history. One resident with Valley Fever said he had come to the facility to see specialists at a Baltimore hospital and had not met the new doctor after several weeks. A representative for one resident stated that no notice was received and that they did not know who was now seeing the resident. The NHA stated that residents were not given a choice at that time and that only one physician was currently coming into the facility.
Residents Not Given Choice of Attending Physician
Penalty
Summary
The facility failed to honor residents’ rights to choose their attending physician for five sampled residents. For Residents 1 and 2, the record showed that Physician 1 had been identified as the primary care provider or attending physician during hospital discharge and transfer documentation, but facility leadership later assigned the facility’s medical director as the attending physician. Resident 1’s history and physical indicated capacity to understand and make decisions, and the resident’s family member stated that Physician 1 had been the resident’s physician for years and that no change had been authorized. Resident 2’s records also showed capacity to understand and make decisions, and the resident stated she did not understand why she was not allowed to keep Physician 1 as her attending physician and that the facility would not allow Physician 1 to see her. For Residents 3, 4, and 5, the admission records, histories and physicals, and interviews showed that each resident had capacity to understand and make decisions, yet none were asked whether they wanted to keep their own attending physician. Resident 3 stated she was not asked and was already assigned the medical director when she arrived. Resident 4 stated she was not asked and was simply informed that whoever was the physician at the facility would be her attending physician. Resident 5 stated he was not asked and was already assigned a physician whom he had never met. Facility leadership and staff stated that the medical director was assigned to residents unless the outside attending physician would follow them in the facility. The admission director stated it was standard practice to assign the facility’s medical director if the resident’s physician was not theirs, and that residents were not asked about a preferred attending physician unless requested. The administrator stated Physician 1 did not have privileges in the facility after 12/2025 and that residents were offered lateral transfer if they wanted to keep Physician 1, while the DON stated residents should be given the option to choose their attending physician as stated in the facility policy. The record also showed that there was no documented evidence that Resident 2 was offered the lateral transfer.
Failure to Honor Resident Choice of Attending Physician
Penalty
Summary
The facility failed to honor a resident’s right to choose her attending physician for resident #57. During an observation and interview, the resident was sitting in a recliner in her room, watching television, and was grimacing while stating she was in pain from a fractured elbow. She said she was unhappy with the physician assigned to her when she was admitted, wanted her own physician to manage her care, and felt unsafe with the new physician because of childhood trauma and not knowing the physician. She stated her primary physician knew her medications and what would be needed to manage her pain, and that she was not given any options to choose her primary physician and was assigned the facility physician. Staff interviews showed inconsistent understanding of how attending physicians were assigned. One staff member did not know how residents were assigned a primary physician on admission. Another stated residents were not given a choice unless their primary was already affiliated with the local hospital physician group, and residents admitted outside the hospital were assigned the medical director. A third staff member stated she understood the regulation to mean residents could choose only physicians already affiliated with the facility and not outside physicians, though after rereading the regulation she understood it required offering outside physicians willing to follow the contract as a primary physician for a resident requesting those services. The facility policy stated residents may choose their attending physician and that alternatives would be discussed if a chosen physician could not meet regulatory requirements.
Residents Not Offered Choice of Attending Physician
Penalty
Summary
The facility failed to ensure that four residents were informed of, and allowed to exercise, their right to choose an attending physician. Resident 1 was admitted with chronic osteomyelitis of the left thigh and osteonecrosis of the left femur and was alert and oriented x3; during interview, she stated she was assigned a facility physician on admission and was not asked whether she wished to retain her own physician or select one of her choice. Resident 2 was admitted for orthopedic aftercare following surgical amputation and was alert, oriented, able to follow commands, and had good safety awareness; she stated her physician was assigned by facility staff and she did not have a choice. Resident 3 was admitted with a fracture of the neck of the right femur and had the capacity to understand and make decisions; she stated she did not have a choice regarding her attending physician and was assigned one upon admission by facility staff. Resident 4 was admitted with difficulty walking and major depressive disorder and was alert, oriented x4 with cognitive status within normal limits; she stated the facility did not ask whether she wanted to choose her own physician or had a preference for an attending physician. Interviews with the Admissions Marketer, Admissions Director, and DON showed that attending physicians were assigned from a panel of approved physicians and rotated among the list. The Admissions Marketer stated residents were not asked whether they had a preferred physician or wished to retain their personal physician upon admission. The Admissions Director stated the attending physician's name was already listed in the admission packet before admission, residents were admitted with the assigned physician, and they were not offered a choice upon admission. The DON stated residents were informed who their assigned physician would be, but were not asked whether they had a preferred physician because the facility assigned physicians from a list of affiliated physicians. The facility's Resident Rights policy stated residents have the right to choose an attending physician and participate in decision-making regarding care.
Failure to Provide Physician Choice Form
Penalty
Summary
The facility failed to ensure that one of three sampled residents had the opportunity to choose his or her attending physician. Resident 1 was admitted with diagnoses including cerebral infarction, dementia, dysphagia, type 2 DM, and bipolar disorder. The H&P dated 3/2/2026 indicated Resident 1 did not have the capacity to understand and make decisions, and the MDS dated 5/28/2026 indicated Resident 1’s cognition was severely impaired and that the resident required extensive assistance with eating, oral hygiene, toileting hygiene, dressing, showering, and personal hygiene. During interview, the ADON confirmed that RP 1 emailed the facility administrator requesting that Resident 1’s primary care physician continue as the resident’s physician while residing at the facility. The ADON stated RP 1 was not provided the facility’s Resident’s Right to Choose a Physician form. The ADON also confirmed that residents have the right to choose their physician and stated that RP 1 should have been provided the form, with social work and nursing staff assisting in contacting the requested physician to determine whether the physician would continue providing care to Resident 1 while admitted to the facility. The facility policy titled Resident Rights stated that residents have the right to choose a personal attending physician and be informed how to contact him or her.
Resident Physician Choice Not Honored
Penalty
Summary
The facility failed to honor residents’ right to choose their attending physician when it discontinued services with Physician A, who had been providing care to 30 residents. Three residents from the sample were reviewed, and one resident who was cognitively intact stated a desire to continue care with Physician A. Instead, on 03/25/26, social services informed the resident that the primary care physician would be changed from Physician A to Physician B, and the change-of-PCP paperwork was signed. The resident’s annual MDS dated 03/04/26 showed the resident was cognitively intact. Social service documentation later noted that the resident was told Physician A would be returning to practice in the facility and was asked whether the resident wanted to go back under that physician as PCP; the resident agreed. During interview, the resident stated he/she did not want to change to Physician B and wanted to stay with Physician A, but did not have a choice. The Administrator stated she expected resident rights to be honored and the resident rights policy to be followed as written.
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