The role of a nursing home attending physician
The nursing home attending physician is the medical doctor responsible for managing the care of the resident. Federal and Georgia law require the attending physician to visit on a routine basis, provide progress notes on each visit, and to be made aware of any changes in condition. This week on the podcast, we go in depth on the role of the attending physician in a Georgia nursing home.
Schenk: Hello out there. Welcome back to the Nursing Home Abuse Podcast. My name is Rob.
Smith: And I’m Will Smith.
Schenk: All right. I have pulled Will back into the studio so to speak for this week’s episode. We’re going to be talking about the role of the nursing home attending physician. But before we get into it, if you are enjoying the content of these episodes, please be sure to like and subscribe. Leave a review if you are so inclined. Go to our YouTube channel, Nursing Home Abuse Podcast on YouTube, leave a comment there, hit the notification bell. With that, let’s get into it.
Will, it’s wild to have you back. It’s almost like I think you were here last month, so we’re pulling you back for your expertise. This week, we’re talking about the nursing home attending physician. So in a nursing home, we have several roles. Actually if you’re interested, there is an episode, because Will worked in a nursing home for over 10 years, we had an episode dedicated to what the role of each person is. But I don’t think we really got to the attending physician. But the attending physician’s role is pretty much outlined in our federal regulations, that is 42-CFR-483.30, physician services. And those provide the obligations and guidelines for attending physicians.
Who is the nursing home attending physician?
Essentially it comes down to this – every nursing home resident needs to be under the care of a medical doctor, not a nurse practitioner, not a registered nurse, not a CNA. The overall care should be supervised by a doctor. So the nursing home attending physician, and Will, correct me if I’m wrong but oftentimes it kind of is baked into the cake, like the attending physician, they’ve got a nursing home and they see everyone in that nursing home as opposed to everybody has to fend for themselves, right?
Smith: Oh yeah, like what you’ll notice is, because I noticed this in our cases, which are all over the state of Georgia, is that you will see a lot of the same names of physicians, because these nursing home attending physicians have a multitude of residents, so they’ll take care of almost an entire nursing home or more, several more nursing homes.
What are the duties of the attending physician in a nursing home?
Schenk: That’s right. So if you’re a resident in a nursing home, you’re essentially assigned an attending physician. Obviously you have the right as a resident, you can have your own primary care physician if you want to, but unless you do that, the nursing home is essentially going to provide one. This is something that’s different than a medical director. Attending physician is actually somebody that is putting hands on the resident and diagnosing them and treating them. So that is what the nursing home attending physician does – supervises care, provides physician’s orders for treatment and sees the resident.
How often should an attending physician visit a nursing home?
So how frequently does the nursing home attending physician need to visit the resident? The answer to that is actually also in the federal regulations. Within the first 30 days of admission to that nursing home, the attending physician needs to lay eyes on that resident. It’s a non-negotiable. The reason why that’s so important is the attending physician is part of the interdisciplinary care team, which is they do the assessment and create the care plan. So the attending physician having to be there in the first 30 days, it’s critical to that process.
And then the attending physician must visit that resident every 30 days for the first 90 days. So states are different with regard to after that first initial visit. Whether or not it has to actually be the attending physician and not a nurse practitioner or not whatever the nurse practitioner equivalent is in your state. In the state of Georgia, the regulations, the Georgia regulations seem to suggest that the attending physician must also do the first couple of visits, and they cannot delegate their duty. But depending on what state you’re in, the attending physician can, once they’ve done that first initial assessment, can delegate, if the medical condition of the resident warrants it, to a nurse practitioner.
Will, in your experience, did you often see the physician or was it like a nurse practitioner?
Smith: So my experience is no. I would rarely see the doctor. Now I don’t want to blame the doctors too much because I had a very sporadic schedule. I would tend to work two months in the summer and maybe I was missing them, but I generally think they’re really not there that much.
Smith: I don’t know what the cause of it is. Certainly, like I said earlier, they have a lot of nursing home residents. It’s not uncommon for them to have over 100 or more, but basically what they’re doing when they do come in is a lot of times, they’re just going through the chart. Back when I was doing it, because I’m very old, we didn’t have electronic records, so they would pick these physical charts up and they would flip through them. They’d ask questions of the nurse, “How is she doing on this? Let me see, maybe I should take her off this or I’ll do this,” and they might talk with the resident if they could, if the resident’s mental state would allow them to answer questions. Yeah, I didn’t really see it that much, to be honest.
When can a nursing home attending physician delegate tasks?
Schenk: We mentioned that the physician needs to visit every 30 days for the first 90 days, but after that, as Will mentioned, you could go long periods of time without seeing them. But under the regulations, it’s once every 60 days. So if your loved one has been in a nursing home for longer than 90 days, it’s once every 60 days as required, although that’s the minimum threshold, but it can be more often than that. But as Will mentioned, it’s likely not, and we have several cases in which the physician never saw the resident. It was always the nurse practitioner, which again, in the state of Georgia, is against the law.
So what are the duties of the attending physician? So obviously the attending physician is there to assess and diagnose and provide what’s called physician’s orders, meaning that by way of example, if a resident has a pressure injury, the physician might say, “Okay, we need to put some type of cream on there. This is how often you bandage it,” that type of thing, and that order stays in the nursing home and is followed by the staff there. The physician is also required for each visit – required to provide progress notes, so that way staff can understand what’s going on and there’s a record because if you’re only going once every 60 days, how are you supposed to remember this type of stuff.
The other duty is the attending physician or any physician, there needs to be 24-hour emergency access to that physician, and Will, you can speak to this about if something happens at 2 in the morning, the nurse or CNA needs to be able to contact somebody who knows what to do.
Smith: Yeah, I don’t want to bash – I have plenty of friends who are doctors and they’re amazing doctors. There’s always bad apples in any arena. Lawyers certainly have their issues, nurses as well. But this is something that my brother Clay talks about a lot because my brother Clay is not only a grown man and a former military medic in the Army, but he’s also, his personality is somebody who isn’t easily startled or frightened. So a lot of times doctors get mad at nurses when they call them for emergencies or there’s some pushback and nurses will feel uncomfortable and they don’t want to call, because doctors essentially are the boss. They’re the person at the very top of the food chain where all orders trickle down from. So to the extent that you’re supposed to call them for an emergency, I know my brother talks about this all the time, he’s had doctors get mad and say, “Why are you calling me?” and he has to set them straight like, “Well if I don’t, this person could die and then you’re on the hook as well as the hospital for malpractice.”
Schenk: Yeah, I’m sure they love that.
Smith: Oh yeah.
Schenk: Yeah, and that’s some of the issues that we see in our cases is that you have a significant change in condition in the resident. The nurse contacts nobody most of the time, but when they do contact the physician, the physician’s like, “Give them some aspirin.”
Schenk: And there’s either miscommunication or no communication or no follow through with the physician. I’ve seen cases where they fax the significant change into the physician and the physician doesn’t get the fax, or vice versa, the physician’s order gets faxed to the facility and there’s no ink in the fax machine.
Smith: Yeah, and I know I just talked negatively about doctors, but I can say that my experience, which is just anecdotal, is that it’s more often than not that the facility that is not communicating properly with the physician. The physician doesn’t know that the resident’s blood pressure has spiked or has dropped or their respirations have changed dramatically, or, hey, this physician wasn’t aware, because he hasn’t been there in 30 days, that this bedsore has gone from stage two to stage one. So I don’t want to put it all on the physician. It’s certainly incumbent, like you said, the facility to make sure the physician knows. Did you get the fax? Did you get the phone call?
Schenk: That’s correct. Not only did you get the fax, F-A-X, did you get the facts, F-A-C-T-S in terms of here are accurate nurse notes that you can look at as you diagnose this particular resident? Because I mean like that’s another problem too, like, “Well nobody told me he was lethargic for the last three days. When I came to him, he was lucid for the five minutes I was there.”
Smith: Oh yeah, I mean it’s absolutely imperative that the entire interdisciplinary team is doing their job. So everybody from the CNAs to dietary, if they’re not accurately assessing and accurately documenting, then when this doctor comes in to look at these notes, she doesn’t know that these aren’t accurate notes. She doesn’t know that their fluid intake has decreased. She’s relying on the staff to give her the information she needs, and all too often, that’s not the case. They’re not accurately documented.
Schenk: That’s right. And so the main point that I would like our audience to take away today is to understand that there should be a physician overseeing the care and that their visits should be periodic. They’re more often at the beginning, not as much afterwards. They can, if they choose, to delegate that task to nurse practitioners down the line, but that does not abrogate the duties that the physician has to make sure that the resident is being taken care of. But to that, I would say this, ask when the next care plan meeting is and also ask when is the physician scheduled to come and visit again, and be there for that. Be there with the physician when they are doing a head to toe assessment of your loved one. You’re allowed to do that if you are the appropriate individual personal representative, but I would say that the more you are involved, the more you know people’s names, like, “Oh, it’s Dr. Johnson, like he’s here today, blah-blah-blah,” the more likely it is that your loved one is not going to fall in the cracks.
Smith: Yeah, I hate saying this but I tell – I have friends call me all the time about loved ones in nursing homes and just making sure that nothing bad happens to them, and I hate saying it but it’s true, the squeaky wheel gets the grease. So the more you’re involved with your care, the more that the team knows that you’re involved and you want to be kept informed, the better care that your loved one is going to get. Should it be that way? No. Everybody should get the same phenomenal care. Unfortunately, they clearly don’t.
Schenk: And to that point, we’ve had episodes about attending care plan meetings. We’ve had episodes about how to get medical records. We’ve had episodes on how to read medical records. Kind of a point I want to highlight for this episode is when you do get the medical records, when you do get the care plan, when you do get the chart because you want to be informed, as Will said, that’s one of the first places you want to go to. You want to go to the care plan first, but then you want to go to physician’s orders, because all too often, our clients come in the door and say, “Your loved one should have been getting their bandages changed and they said, ‘No, that’s not what the doctor wanted,’” or “I didn’t understand why they’re getting this medicine and they said the doctor said they wanted it, and the last time I saw the doctor, they said they didn’t want it,” or whatever the case may be. There’s confusion about what the doctor wants. So when you get the chart, when you ask to see the records and you get them, go to the physician’s orders and read the physician’s orders. Remember to a large extent, the physician’s orders should be in a language that a CNA can understand, which means that it’s pretty close to layman’s terms.
Smith: Oh, absolutely.
Schenk: So if the physician’s order is for a bandage to be changed three times a day or whatever the case, three times a week, whatever the case may be, look and see. Verify that so that way if you get any pushback from the staff, you can say, “Hey, I’m holding up the physician’s orders. Why aren’t you doing this?” So that’s a recommendation, not only be there when the physician’s there but get a hold of the physician’s orders.
Smith: And I think that we talked about this the last time that I was on when we were talking about incontinence, just knowing the side effects of different medication. So talk with the physician. You have every right to do that. This physician is your loved one’s doctor, so ask them, “What are the side effects or things that we need to look out for? For example, are they on pain medicine that might cause constipation? Is that going to be an issue? What should the staff do?” Get involved.
Schenk: That’s right. It’s almost like if you’ve ever seen any commercial for medication in the past 35 years, there’s that litany of like, “This may cause loose stools, diarrhea, blah-blah-blah, blah-blah-blah.” You want that explained to you by that physician but slower.
Smith: Yeah. “What are we looking at here? Because you’re giving my mother these medications, what are the side effects going to be? What are the common side effects? And what does that staff need to do? What do we need to do?”
Schenk: That’s right. So that hopefully answers some of your questions about who an attending physician is, who they are in the hierarchy of care and how often you should be seeing them with regard for caring for your loved one.
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Smith: See you next time.