Ftag of the Week – F635 Admission Physician Orders for Immediate Care

This week’s CMSCG Blog “Ftag of the Week” is F635 Admission Physician Orders for Immediate Care, which is part of the Resident Assessments regulatory group. While this Ftag has been infrequently cited in 2019, it has been cited at about a 50/50 split between recertification and complaint surveys, so it is not just an issue that will be identified due to a complaint.

F635 requires that, upon admission to the facility, each resident has written and/or verbal physician orders for essential care to be provided for the resident. This includes, minimally, routine care to maintain/improve the resident’s functional abilities, his/her medications and dietary needs. On recertification surveys, this is commonly cited for:

  • Lack of physician orders for medications
  • Lack of orders for care for devices such as Mediport, PICC lines or Foley Catheters
  • Lack of clarification of admitting orders

In reviewing complaint survey citations at F635, many of the same issues noted above are cited, but instead resulted in an avoidable outcome:

  • Med Orders – Admission RN reviewed the wrong medication orders with the physician, resulting in the incorrect medications being administered and the resident being transferred to the hospital in a-fib
  • Device Care – Resident had a midline catheter upon admission that was not documented, resulting in no care being provided for 4 months to the catheter site that ultimately ended up infected
  • Contact with Physician for Clarification – Resident admitted to the facility without discharge orders and staff did not follow up in a timely manner, resulting in a resident not receiving IV antibiotics which were ordered for two weeks. No documentation was provided to show that the staff had contacted the physician for orders for several days after admission.

Examples such as these can be reflective of an admissions process that assigns staff to be accountable for conducting an initial review of the paperwork that is received by the facility during admission, but may not including ensuring that there is an additional check by another facility staff member. The initial review needs to be comprehensive and include a careful review of medication orders as well as looking at areas that might require treatment or consult orders, etc.

Unfortunately, errors, some major and some minor, do occur related to these reviews and result in all necessary orders that should be in place at the time of admission being “missed.” When an issue is identified in your facility with any type of order not being documented at the time of admission, administration needs to reassess the performance of the responsible medical staff member.

Missing orders at the time of readmission after a hospitalization can result in a high level deficiency if the provided documentation is not carefully reviewed and the physician does not document all orders necessary to ensure the resident’s total program of care is addressed.  If you have a solid system, you are not going to miss the need for ongoing antibiotic therapy, wound care, or ordering of an anti-rejection medication for a transplant. Make sure that your staff understands their responsibilities for ensuring admission orders are comprehensive and accurate.

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