COLORADO SPRINGS, CO - Federal inspectors cited Falcon Heights Rehabilitation and Nursing LLC for failing to obtain proper consent when the facility's corporate ownership changed primary medical groups serving residents.
Unauthorized Medical Provider Change
The facility violated federal regulations by switching medical groups without informing residents or their families and obtaining required consent. According to the inspection report, the corporate decision affected all patients under the previous medical director's care, transferring them to a new physician group without proper notification procedures.
The Director of Nursing confirmed that the transition created significant operational challenges. The new medical group took over a month to begin seeing residents at the facility, creating a gap in continuous medical care that federal regulations specifically require nursing homes to maintain.
Communication Failures Create Medical Risks
The most concerning aspect of the transition involved the new medical group's failure to respond to urgent nursing calls. According to facility staff, the new physicians would not return calls to nursing staff overnight or on weekends, forcing nurses to seek alternative medical guidance.
The Director of Nursing implemented an emergency protocol directing nurses to contact the retired medical director if they did not receive callbacks within 15 minutes. This workaround highlighted the breakdown in the facility's medical oversight system and created potential liability issues.
One documented incident involved Resident #9, who experienced a change in condition on June 4, 2024. When nursing staff could not reach the on-call physicians despite leaving multiple messages, they contacted the retired medical director for guidance. Since this resident was no longer under his care, the retired physician appropriately declined to provide treatment orders over the phone and recommended emergency room evaluation.
Medical Standards Violated
Professional medical standards require physicians to see residents within 24 to 48 hours after hospitalization or significant health changes. However, the retired medical director reported that Resident #9 was not seen by facility physicians for more than 10 days following her initial condition change on June 4th.
This delay violates established care protocols and creates risks for medication management, treatment plan adjustments, and monitoring of recovery progress. When residents return from emergency rooms, prompt physician evaluation ensures proper follow-up care and prevents complications.
Regulatory Requirements for Provider Changes
Federal nursing home regulations specifically require facilities to inform residents and their responsible parties when changing medical providers. This notification process allows families to understand care transitions and ensures continuity of medical records and treatment plans.
The consent requirement protects resident autonomy and allows families to make informed decisions about their loved ones' medical care. When facilities bypass these protections, they violate fundamental patient rights established under federal law.
Impact on Patient Care Quality
The Director of Nursing expressed frustration about the situation, acknowledging that the communication failures had "the potential for negative outcomes for residents." This admission reveals the facility's awareness that their operational decisions created medical risks.
Nursing staff also reported frustration with the new medical group's unresponsiveness, indicating systemic problems with the transition that affected day-to-day patient care. When nurses cannot reach physicians for urgent medical guidance, residents face delayed treatment and potential complications.
Industry Standards and Expectations
Nursing facilities must maintain 24-hour physician availability either through on-site coverage or reliable on-call systems. The Medicare and Medicaid programs require this coverage as a condition of participation, making physician responsiveness a federal compliance issue.
Professional medical associations recommend that nursing home physicians establish clear protocols for after-hours communication and maintain response times appropriate for the acuity level of nursing facility residents.
Enforcement Actions
Federal inspectors classified the violations under tags F555 and F684, relating to resident rights and physician services respectively. The facility received citations for minimal harm with potential for actual harm affecting few residents.
These violations require the facility to submit corrective action plans demonstrating how they will prevent similar incidents. Facilities must show they have implemented systems to ensure proper notification procedures for any future provider changes and established reliable physician communication protocols.
The inspection findings highlight the importance of proper transition planning when nursing facilities change medical providers, emphasizing that corporate decisions must comply with federal patient protection requirements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Falcon Heights Rehabilitation and Nursing LLC from 2024-07-31 including all violations, facility responses, and corrective action plans.
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