Failure to Honor Resident’s Choice of Psychiatric Provider and RP Authority
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.
Penalty
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
The facility discontinued use of a long-time attending physician and did not allow that physician to continue providing care within the facility, despite residents’ stated wishes to keep this provider. According to the admission agreement, residents could select their own qualified healthcare professionals, but after the facility cited concerns about the physician’s failure to sign orders, complete Medicare certifications, and enter timely progress notes, residents were asked to transition to another physician. Cognitively intact residents reported being automatically reassigned to a new physician, described being upset about losing their long-standing physician and NP relationships, and said their questions about what happened to the prior physician were ignored or minimally addressed. A group of residents stated that a sheet was passed around informing them the physician had been dropped and a new doctor assigned, while leadership reported that residents could only continue seeing the former physician outside the facility, effectively preventing them from exercising their choice of attending physician for in-facility care.
Failure to Honor Residents’ Choice of Attending Physician: Three cognitively intact residents said they were not allowed to choose their own attending physician and were required to see the facility MD instead. EMR and admission agreement review showed no documentation that they were offered a choice of physician, despite one resident wanting to continue with a community PCP. The NHA stated residents could choose their attending physician, but also said the facility had only one physician available for residents to choose from.
The facility discontinued services with one attending physician and reassigned multiple residents to new physicians without honoring their right to choose their own provider. Two residents with no cognitive impairment and histories including stroke, cancer, diabetes, high blood pressure, and depression reported they were told their physician would no longer be available and that they would be assigned a new one, without being asked for their preference or given an opportunity to remain with their original physician. One resident, who stated he/she was his/her own guardian and POA, was documented as having a guardian notified of the change, despite no guardian being recorded in the chart. The Administrator and DON reported they followed a corporate directive to notify residents of the change, did not send written notices, and did not ask residents if they wanted to change physicians, despite a policy stating residents have the right to choose their attending physician and be fully informed in advance of changes in care.
The facility discontinued services with a long-standing attending physician and reassigned all affected residents to another physician despite many residents and their representatives clearly expressing a desire to remain with the original provider. Social Services documented that residents and guardians were informed of their right to choose a physician and were told they could continue with the original physician through outside appointments with facility-assisted transportation, yet medical records were changed to list a different PCP, and no transportation was actually arranged. Several cognitively intact or partially impaired residents, and guardians for residents with severe cognitive impairment and complex conditions such as HTN, DM, stroke, CP, schizophrenia, and dementia, reported wanting to keep the original physician but felt compelled to accept the change due to statements that the physician would no longer be allowed in the facility and lack of practical means to access outside care. The DON later confirmed that residents were switched to a new PCP because of a corporate deadline and that no transportation had been set up for those wishing to remain with the original physician.
A resident on hospice with osteomyelitis, ESBL, severe PUs, and other comorbidities had chosen a hospice physician to manage her care, but the facility refused to accept that physician’s orders for PU treatment. Instead, due to the lack of an in-house wound care nurse, the facility arranged repeated out-of-town wound clinic visits for wound care, as confirmed by the POA, the hospice executive director, and the ADON, and documented in multiple progress notes.
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Failure to Honor Residents’ Choice of Attending Physician After Discontinuing a Provider
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when it discontinued services with Physician RR and did not permit this physician to continue providing care within the facility. The admission agreement stated that residents may select qualified healthcare professionals who conform to facility policies and applicable laws and that the facility may require credentialing. It also stated the facility may assist residents in selecting another physician if a physician fails or refuses to meet statutory or regulatory requirements. The facility issued a letter, dated 4/10/26 and signed by the administrator, stating that Physician RR continued to fail to sign orders, complete Medicare certifications, and timely enter progress notes, and that residents under this physician’s care were being asked to transition to alternative physicians. Resident #133, cognitively intact with diagnoses including anemia, heart failure, hypertension, stroke, anxiety, depression, and a psychotic disorder, had been under the care of Physician DD as primary physician and Nurse Practitioner SS as alternate, and was his/her own responsible party. The resident reported receiving the letter about Physician RR and stated that residents were upset because they had been with Physician RR for many years. The resident said that when he/she asked staff what happened to Physician RR, staff ignored the question, and when he/she asked social services, he/she was simply told that the new physician was Physician DD. An LPN reported that Resident #133 wanted to keep Physician RR and had a rapport with this physician, but the resident was transitioned to the new physician instead of being allowed to continue with Physician RR in the facility. Resident #139, also cognitively intact with diagnoses including hypertension, anxiety, depression, schizophrenia, PTSD, and asthma, was his/her own responsible party and had Physician DD documented as primary physician. This resident stated that many residents wanted to keep Physician RR, but they were automatically enrolled with Physician DD whether they wanted to or not, and the resident chose not to contest the change despite a long-standing rapport with Nurse Practitioner SS. In a group interview, nine residents reported that the facility “dropped” Physician RR about a month earlier and passed around a sheet stating they were not using Physician RR and had a new doctor. The DON stated that Physician RR was difficult to reach, did not sign orders or return calls, and was no longer the facility’s primary physician as of the prior month, while also stating there were no residents who expressed feelings about losing Physician RR. The administrator reported that residents received 30 days’ notice of the primary physician change and that residents could continue to see Physician RR only outside the facility, indicating that residents who wished to retain Physician RR for in-facility care were not allowed to do so.
Failure to Honor Residents’ Choice of Attending Physician
Penalty
Summary
The facility failed to ensure three cognitively intact residents were allowed to choose their own attending physician. Resident #15, Resident #28, and Resident #30 each stated during a group interview that they did not have a choice in who their physician could be while in the facility and that they had to see the facility’s MD. Resident #15 said she had a primary care physician in town that she wanted to continue seeing, but she was told she could not see that physician. Resident #28 and Resident #30 each said they were required to see the facility’s MD instead of choosing their own physician. Record review for each of the three residents, including the admission agreement and EMR, showed no documentation that they were provided a choice of attending physician. Resident #15 had diagnoses including COPD, cirrhosis of the liver, and osteoarthritis, and her MDS showed she was cognitively intact with a BIMS score of 15. Resident #28 had diagnoses including type 2 diabetes mellitus, asthma, osteoarthritis, and TIA/cerebral infarction, and was also cognitively intact with a BIMS score of 15. Resident #30 had diagnoses including type 2 diabetes mellitus, wedge compression fracture of T11-T12 and L3, and hypertension, and his MDS likewise showed a BIMS score of 15. The NHA stated residents were able to choose their attending physician when admitted, but also said the facility had one physician residents could choose from and was not aware that these residents wanted different physicians.
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The facility failed to honor residents’ rights to choose their own attending physician after discontinuing services with Physician A, who had been providing care to 15 residents. The facility’s Resident Rights policy states that residents have the right to choose a personal attending physician, be fully informed in advance about care and treatment and any changes that may affect their well-being, and participate in planning their care and treatment. Despite this, when corporate notified the Administrator via email that Physician A would no longer have privileges at the facility, the Administrator and DON implemented the change by informing residents and their representatives that their primary physician would be changed, without offering a choice or obtaining resident input. No written notices or letters were sent to residents, responsible parties, or guardians about the physician change. Resident #2, who had no cognitive impairment and diagnoses including stroke, cancer, and diabetes, was documented as having a call placed to a “guardian” about the primary doctor change, even though the medical record contained no documentation of a legal guardian and the resident stated he/she was his/her own guardian and power of attorney. The resident reported being told that Physician A would no longer be at the facility and that he/she had to go with another physician, despite expressing a desire to remain with Physician A. Resident #7, who also had no cognitive impairment and diagnoses including high blood pressure, stroke, and depression, was notified via a progress note that Physician A would no longer have privileges and that he/she would have a new physician. In interview, this resident stated he/she was not asked to change physicians, would have liked to stay with Physician A, and would have appreciated being asked. The DON acknowledged that she informed residents of the change but did not ask if they wanted to change physicians, and both the Administrator and DON stated the resident rights policy should have been followed as written.
Failure to Honor Residents’ Choice of Attending Physician After Termination of Physician Privileges
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their own attending physician after corporate leadership discontinued privileges for Physician A, who was caring for 35 residents. The facility’s Resident Rights policy states that residents have the right to choose a personal attending physician, be fully informed in advance about care and treatment and any changes that may affect their well-being, and participate in planning care and treatment. In early March, the DON and Administrator received an email from the corporate CNO stating that, effective at the end of the month, Physician A would no longer have privileges with the organization and instructing them to notify residents of the change and determine whether they wanted to stay with Physician A. Despite this, all of Physician A’s residents were changed to Physician B by the facility due to a corporate deadline, and no letter was issued to residents regarding the change. Multiple residents and their representatives expressed a clear preference to remain under the care of Physician A, but the facility did not coordinate continued access to that care. One cognitively intact resident with anxiety and depression was informed by Social Services that Physician A would no longer maintain privileges and that continued care would require outside appointments, with the facility assisting with transportation. The resident stated a desire to stay with Physician A, citing satisfaction and desire for continuity, yet the medical record listed Physician B as the PCP, and the resident later reported being told by the Activity Director that he had to change physicians because Physician A could no longer practice at the facility and the office was too far away. Another resident with moderate cognitive impairment, high blood pressure, anxiety disorder, and schizophrenia similarly expressed a preference to remain with Physician A, and Social Services documented that transportation assistance would be provided; however, the medical record also showed Physician B as the PCP, and the resident’s family member reported not being notified of the PCP change and wanting the resident to keep Physician A. Additional residents and guardians experienced the same pattern. A resident with no cognitive impairment, high blood pressure, and schizophrenia had a guardian who was notified that Physician A would lose privileges and who clearly stated a preference to keep Physician A, yet the resident’s record listed Physician B as PCP, and the guardian believed Physician A was still the PCP. Two other residents with severe cognitive impairment and diagnoses including stroke, cerebral palsy, high blood pressure, diabetes, and dementia were informed, along with their family, that Physician A would no longer have privileges and that continued care would require outside appointments with transportation assistance from the facility. Both residents expressed a preference to remain with Physician A, but their records listed Physician B as PCP. Their guardian reported being told that Physician A would no longer be allowed in the facility and, lacking a car to transport the residents, felt there was no real choice and agreed to the change. The DON later acknowledged that transportation had not been set up for residents who wanted to stay with Physician A and that, to her knowledge, Physician A did not have an office, while Physician A’s office manager stated that Physician A had not had an examination office for about 15 years and preferred to see residents onsite in the facility. These actions and omissions resulted in residents’ stated choices to remain with Physician A not being honored or facilitated.
Failure to Honor Hospice Physician Choice for Wound Care Management
Penalty
Summary
The facility failed to honor a resident’s right to choose her attending physician by refusing to accept medical orders from her selected hospice physician for treatment of her pressure ulcers. The resident was admitted with multiple serious conditions, including osteomyelitis, ESBL, an unstageable right heel pressure ulcer, a stage 4 sacral pressure ulcer, hypertensive heart disease without heart failure, a cutaneous abscess of the buttock, and an attention and concentration deficit. Her record showed an order for admission to hospice care, and the resident’s Power of Attorney reported that hospice had been chosen so that the hospice physician would manage her care. However, the POA stated that the facility would not accept the hospice physician’s orders for pressure ulcer care and instead required the resident to attend appointments at an out-of-town wound clinic. The Hospice Executive Director confirmed that the facility contacted her to obtain permission to send the resident to a wound clinic because they did not have anyone in-house to provide the needed wound care. She explained that facility nurses are responsible for providing continuous wound care, with a hospice nurse providing wound care and measurements once weekly, yet the facility continued to send the resident to the wound clinic despite her being on hospice. The ADON stated that the resident was going to the wound clinic because the facility did not have a wound care nurse. Progress notes documented multiple dates on which the resident had out-of-town wound clinic appointments, demonstrating the facility’s ongoing reliance on the clinic rather than accepting and implementing the hospice physician’s orders for pressure ulcer management.
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