The incident occurred during a July 28 virtual appointment at Ambassador Healthcare, where Resident B was scheduled for a post-surgical follow-up with neurosurgery at 9:15 a.m. The resident had undergone back surgery and was supposed to have a back brace at the facility.
Resident B's family member told inspectors during an August 11 interview that she and the resident both wanted to speak with the surgeon about a fall that had happened the day before the appointment. They also needed to discuss the facility not having the required back brace.
The morning of the appointment, Licensed Practical Nurse 3 came into Resident B's room and mentioned using a tablet for the virtual visit. When the family member said she wasn't sure how to use the tablet, she asked the nurse to have the doctor's office call her phone instead so both she and the resident could participate.
"The family member indicated the resident was capable of participating in the virtual meeting and had questions and so did the family," the inspection report states.
Instead, LPN 3 took the phone call alone.
During her August 12 interview with inspectors, LPN 3 said she didn't know how to use the tablet for virtual doctor visits. When the neurosurgeon's office called the facility, she answered, provided information, and received new orders.
She told inspectors "she did not think the family needed to be in on the phone call."
The unit calendar for July 28 showed Resident B had a neurosurgeon virtual visit scheduled at 9:15 a.m., along with the neurosurgeon office's phone number. Hospital discharge instructions confirmed the virtual follow-up appointment was scheduled for that exact time.
LPN 3 acknowledged that Resident B's wife had set up the virtual appointment at the hospital but said she was "unsure what phone number she gave them."
The facility's Director of Nursing told inspectors that physician offices usually call the facility to set up virtual visits and provide an email or code for their tablet "so everyone can be involved."
That didn't happen in this case.
Executive Director revealed during his August 12 interview that Ambassador Healthcare had no policy regarding virtual doctor appointments. This absence of protocols left staff without guidance on how to handle family participation in telehealth visits.
The violation occurred just one day after Resident B had fallen while missing the required back brace. The family's concerns about both the fall and the missing medical equipment made their participation in the neurosurgeon follow-up particularly important.
Federal regulations require nursing homes to allow residents to participate in developing and implementing their person-centered plan of care. This includes involving residents and their families in medical appointments when requested.
The inspection report notes that LPN 3 received new orders from the neurosurgeon during the call but provides no details about what those orders contained or whether they addressed the family's concerns about the fall and missing back brace.
Resident B's family member had specifically requested that both she and the resident speak with the surgeon. The resident was described as "capable of participating in the virtual meeting" and having questions for the medical team.
The exclusion of family members from medical appointments can have serious consequences for patient care, particularly when families have specific concerns about treatment or safety issues like missing medical equipment.
Ambassador Healthcare's lack of virtual appointment policies left nursing staff to make individual decisions about family involvement without clear guidance. The Director of Nursing's comments suggest the facility understood that virtual visits should include all relevant parties but failed to ensure this happened.
The incident highlights gaps in telehealth protocols at nursing facilities, where family participation in medical care has become increasingly important during the era of virtual appointments. Without clear policies, residents and families may be excluded from critical medical discussions about their care.
Resident B's case demonstrates how procedural failures can compound medical concerns, leaving families without answers about falls, missing equipment, and post-surgical care when they need information most.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ambassador Healthcare from 2025-08-12 including all violations, facility responses, and corrective action plans.
