RICHMOND, Va. — Doctors are only required to visit new residents in skilled nursing facilities within 30 days of admission, and only twice within 90 days, according to federal rules sent to CBS 6 by the Virginia Department of Health’s Office of Licensure.
That means a resident could be discharged from a hospital to a rehab center in a fragile state and never be seen by a doctor before they leave, whether to go back to the hospital or home.
That appears to be what happened to Kathy Stiltoner.
Even when Stiltoner’s body started to betray her in 2022 due to chronic diabetes and painful osteomyelitis, an infection of the bone, her daughters held out hope she would regain her mobility.
They agreed that a skilled rehab facility would help her reach that goal.
“We are our mother's voice, and I'm glad you're letting us tell mom's side of the story,” said Kaitlyn Cothron, one of Kathy’s daughters.
Her daughters held out hope that she would regain her mobility and agreed that a skilled rehab facility would help her achieve that goal.
“Once they fixed the MRSA, they wanted her to go to Westport for skilled rehab for her to be able to use her hands and legs,” said Brittney Marine, another one of Kathy’s daughters.
Stiltoner entered Westport Rehabilitation and Nursing Center in Henrico on November 30 of that year.
Facility staff noted she had a stage two pressure ulcer on her sacrum upon admission, according to medical records.
Stiltoner was then diagnosed with COVID-19, so her daughters were not allowed to see her for 10 days.
When she finally got inside to see her mom, Cothron said she was taken aback.
“She was so dehydrated, very delusional,” she said. “She wasn't recognizable, her face had drawed in, her lips were crusted over.”After just 20 days there, the daughters said they insisted their mom be removed by ambulance from Westport and taken to the hospital.
That is where doctors found she had acute metabolic encephalopathy in the setting of a UTI, and the ulcer had worsened to a stage four.
Staff at VCU had to debride the wound and attempted surgery to divert waste away from that area through an ostomy.
Stiltoner told a chaplain at the hospital that she had a previous bad experience with rehab. The chaplain described her as “tearful and scared about her upcoming transfer out of the hospital to a nursing home."
According to Stiltoner’s medical records, she had a primary physician at her new facility: the same doctor listed as medical director in license renewal application documents for Westport in 2023.
“When you see that name, what comes to mind?” CBS 6 investigative reporter Melissa Hipolit asked the daughters, pointing to the name of their mother’s attending doctor at Westport.
“I don't know who that is,” Marine said.
CBS 6 couldn’t find anything in the medical records from Stiltoner’s time at Westport, provided to us by a former lawyer for the family, showing that the doctor ever laid eyes on her.
That lawyer said he could not 100% confirm that the doctor’s records would be included with the ones that he received, but he said he felt like they would be if they existed.
We did find a record that showed a psychiatric doctor visited her.
Colonial Heights Rehabilitation and Nursing Center
Stiltoner remained at VCU for a couple of months until she was transferred to Colonial Heights Rehabilitation and Nursing Center in February of 2023.
Prosecutors have charged multiple staff members at that facility in connection with the death of a patient and alleged elder abuse.
Watch related coverage: Criminal charges against Virginia nursing home staffers to be upgraded
In addition, the medical director at Colonial Heights was charged with abuse of a vulnerable adult for what prosecutors call a “lack of oversight of patient care” in a separate case.
Neither of those criminal cases involve Stiltoner.
Colonial Heights and Westport are owned by the same company, Medical Facilities of America (MFA), according to VDH and the Virginia Attorney General’s Office.
Watch related coverage: As embattled Virginia nursing home provided low-rated care, financial records show it was 'highly profitable'
Marine said she made a disturbing discovery after arriving to feed her mother breakfast one month after her transfer to Colonial Heights.
“When I walked in, my mother was hanging off the bed with her arms in the air,” Marine said. “I called EMS, EMS arrived, my mother's sugar dropped to 53, and they transported her to Southside.”
After the hospital visit, Stiltoner went back to Colonial Heights.
Her daughters ultimately pulled her out on May 9th of 2023.
She died a few weeks later at the age of 61.
Among the causes of death on her death certificate was the stage four sacral ulcer.
What is the role of a doctor in a skilled nursing home?
The experience left her daughters wondering: what exactly is the role of the Medical Director and attending physicians at these nursing facilities?
“Those patients are your responsibility. That’s somebody's mom and dad,” Marine said.
Dr. Jim Wright, the Medical Director at the not-for-profit Lakewood Retirement Home in Henrico, said he takes that message to heart.
He has worked in various facilities across Virginia for 25 years.
“We are in an advisory role to the nursing staff, Director of Nursing, Administrator to make sure that appropriate medical care is being given to patients,” Dr. Wright said about the Medical Director role.
Dr. Wright even started his own geriatric specialist group, SNF/LTC Partners of Virginia, aimed at ensuring patients in long-term care and skilled nursing facilities are seeing their doctors as much as they should be.
“Certainly when someone is first coming in physician involvement, certainly for their history and physical, which should occur within the first few days, and then ongoing visits by the physician for at least two to three weeks, and I would say on a weekly basis is super important for the success of a rehab stay,” Dr. Wright said.
What is the role of a Medical Director in a skilled nursing home?
But state and federal laws do not require that, nor does the law require that a facility’s Medical Director do the examination.
Instead, they mandate that a physician do an initial comprehensive visit on a patient within 30 days of admission.
Inspectors are advised to not "specifically look at the timetables for physician visits unless there is indication of inadequate medical care” when they are surveying a facility.
“Even though nurse practitioners are very capable of addressing the majority of our skilled nursing patients, the physicians with their better training, their scientific grounding, are extremely vital in those first few days to make sure the care is appropriate, the medications are appropriate for each patient,” Dr. Wright said.
After that, doctors have to see their skilled rehab patients every 30 days, but every other one of those can be delegated to a non-physician practitioner (NPP), which means a nurse practitioner (NP), clinical nurse specialist (CNS) or physician assistant (PA).
Doctor Wright said physicians should be checking in with their rehab patients much more frequently, especially because he said in the past 25 years, Medicare revisions mean acutely ill patients are getting discharged from the hospital into rehabs much quicker.
“And you don’t necessarily think some of these facilities have caught up to that change?” Hipolit asked Dr. Wright.
“I have seen that to be the case, yes. A lot of us are still practicing 1990s medicine, where physicians could come by the nursing home once a week or once a month and treat their long-term care patients. That is not the case now, and I think some physicians haven’t caught up to that,” Dr. Wright replied.
By law, nursing homes and rehabilitation centers have to employ a Medical Director to oversee care, but that doctor does not have to actually visit with patients.
“The Medical Director would be monitoring all the care of the patients. They would be alerted if there were any deficiencies in care, and they would contact the physician, the nurse practitioner, and make sure they understand standards of care and bring them up to standards of care if they need that,” Dr. Wright said.
There is also no cap on the number of facilities a doctor can be the Medical Director of.
CBS 6 found out from VDH that Stiltoner’s attending physician at Westport is the medical director for 31 nursing homes across Virginia.
In comparison, the Medical Director at Colonial Heights Rehabilitation and Nursing Center is the medical director at three facilities in Virginia.
VDH spokeswoman Maria Reppas said there is no limit to the number of patients the Medical Director can have if they have sufficient extenders, like nurse practitioners, to meet the requirements of the facility.
We also found that some of the attending physicians for skilled rehabs and nursing homes in our area have other doctor jobs as well.
“Is that common that these doctors would have second jobs? This is just kind of a side thing?” Hipolit asked Dr. Wright.
“I think that is common in other groups, yes,” he replied. “I've found, personally and professionally in my life, I am really unable to manage more than two skilled nursing facilities. It's impossible for me to be there and treat patients appropriately in more than two skilled rehab facilities."
Medical records show a physician at Colonial Heights visited Stiltoner once or twice a week while she was there, but, even that, her family argues, is not enough.
"I do feel like if I would have brought her home sooner and didn’t listen to what she said then I could have saved her," Marine said.
We reached out to a spokesperson for the ownership at Westport and Colonial Heights to share Stiltoner’s daughters’ concerns.
Their publicist, Mindie Barnett, said she had no comment due to HIPAA sensitivity.
We also reached out to Stiltoner’s doctor at Westport.
A lawyer responded and said it was clear any information we received was incomplete or inaccurate, but when we asked for medical records that could show the doctor visited Stiltoner, the lawyer said they were unable to provide such information due to legal and privacy restrictions.
One of Stiltoner’s daughters filled out a HIPAA authorization form and permitted us to view the records, but the lawyer responded that all requests for medical records should be directed to the facility.
As for the doctor’s Medical Director role at 31 different facilities, the lawyer wrote, “we are not familiar with the specifics of the information you claim to have received from VDH and, as such, will not be addressing these questions.”
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