Failure to Designate a Medical Director for Resident Care Oversight
Penalty
Summary
The facility failed to designate a physician to serve as Medical Director responsible for implementation of resident care policies and coordination of medical care, affecting all 52 residents in the facility. The DON reported that the former Medical Director retired in June or July and that the position had not been filled since that time. The Administrator confirmed that the Medical Director position had been vacant since July 2025 and that the local medical physician group would not contract with the facility. The facility had attempted to contract with two other medical groups and was in ongoing contract negotiations with a physician from one of those groups, but no formal appointment had been made. During interviews, the DON stated she was the only person reviewing clinical trends and participating in QAPI clinical review, indicating that physician-level oversight of these functions was not in place. The Administrator stated that, in the absence of a Medical Director, they had informal conversations with physicians when they rounded at the facility, but there was no formal notification to the Governing Body regarding the vacancy, although ownership was verbally informed in daily conversations. The Administrator was unsure how physician-level oversight, contractual obligations, and compliance with federal requirements had been achieved since July 2025. This situation existed despite a written Medical Director policy, last reviewed on 3/2/25, that outlined extensive responsibilities for the Medical Director, including implementation of resident care policies, coordination of medical care, evaluation of staff adequacy, review of incidents and accidents, and participation in QAPI meetings.
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