Who is responsible for medical care in a skilled nursing facility
Primary care follow-up in skilled nursing starts with the attending physician. Every resident has one, and that physician is responsible for the resident’s medical care. Nurse practitioners and physician assistants often work alongside. Facility nurses carry out the orders, watch residents day and night, and report changes.
So follow-up here is not about adding another doctor. It is about making sure the medical side keeps pace with the resident: conditions reviewed, medications checked after a hospital stay, new symptoms assessed, and a plan in place for what comes next.
Gateway’s role is coordination. We work with attending physicians and facility teams. We do not replace them.
Short stays and long stays need different things
Short-stay residents usually arrive from a hospital for rehabilitation. Their medications have often changed, and their regular physician may not know about the admission. For them, the most important primary care question is what happens on the day they go home.
Long-stay residents live at the facility, and the attending physician manages their chronic conditions over months and years. For them, the questions are about steady follow-up, changes in condition and care that matches their goals.
Where wounds come into it
Many residents have a wound or are at risk for one: a surgical incision, a pressure injury, a diabetic foot ulcer or a leg ulcer. How a wound responds depends on conditions the attending physician manages, including blood sugar, nutrition, circulation and medications.
Gateway arranges facility wound rounds with partner wound clinicians. For those rounds to help, information has to move both ways. The wound clinician’s findings need to reach the nursing team and the attending physician, and the attending’s medical decisions need to reach the wound clinician.
A wound visit often surfaces medical questions. A resident is losing weight. Leg swelling is worse than last week. Those observations belong with the attending, and part of our job is making sure they get there.
What Gateway arranges in a facility
- Scheduling Gateway clinician visits with the facility, within its policies and routines
- Sharing visit notes and recommendations with the nursing team and the attending physician
- Flagging wound-related concerns that need a medical decision
- Gathering outside records, such as hospital discharge summaries
- Helping arrange supplies, referrals or transportation when the treating clinician orders them
Clinical decisions stay with the attending physician and the treating clinicians. Our page for skilled nursing facilities describes how we work with facility staff.
Planning for the day of discharge
The move from a facility back home is a common point for care to slip. Medication lists change again, the home physician may not have the records, and a first appointment can be weeks away.
For residents returning home in Greater St. Louis and the Metro East, Gateway can arrange in-home primary care follow-up with Gateway clinicians, along with wound care if a wound is still healing. If the resident has a physician, we keep that office involved. If not, we help connect the resident with a practice. Our page on transitional care after discharge explains this period.
Questions families can ask the facility
- Who is the attending physician, and who sees residents between that physician’s visits?
- Whom do I call with a concern, and who calls me when something changes?
- Has the medication list been compared with what was taken at home?
- Is there a wound or a skin risk, and who is following it?
- What is the plan for discharge, and who will provide medical follow-up afterward?
Two guides can help you prepare: what to ask when a loved one moves to skilled nursing and preparing for a facility care plan meeting.
Changes to tell the nursing staff about
Families often notice changes first, because they know what is normal for the person. Tell the nurse if your relative seems more confused or sleepy, is eating much less, has new pain or swelling, or has a dressing that is soaked or coming off. Mention any redness over the tailbone, hips or heels.
Facility staff respond to emergencies and call 911 when needed. If you see trouble breathing or a sudden change in alertness during a visit, alert staff right away.
How to start
Families can call 314-325-0126 or request a callback with a name and phone number. Facility teams, attending physicians and discharge planners can refer a resident or call the same number. Please keep clinical details out of the web forms.
Common questions
Can my own doctor keep seeing me in a skilled nursing facility?
Only if your doctor sees patients at that facility, and many office-based physicians do not. In that case, a physician who visits the facility becomes your attending during the stay. You can ask the facility to send records to your regular doctor.
How often does a physician see residents in skilled nursing?
Federal and state rules set a minimum schedule for visits by the physician, and the attending or a nurse practitioner may see a resident more often when there is a need. Ask the facility how often your relative will be seen and how you will hear the results.
Does Gateway replace the facility’s physician or nursing team?
No. The attending physician directs medical care and the facility’s nurses provide daily care. Gateway arranges visits by Gateway clinicians and coordinates communication, so their recommendations reach the people responsible for the resident. Every order and treatment decision is made by the attending physician or the treating clinician.
What should I do if I think a wound is being missed?
Start with the nurse caring for your relative, then the unit manager or director of nursing. Ask what the wound looks like, how it is being measured and who is following it. You can also raise it at the care plan meeting. The attending physician decides whether a wound clinician should be consulted.
Related pages
General information to help you talk with your own clinician. It is not medical advice, and the treating clinician makes every clinical decision. For a medical emergency, call 911.