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F0635
E

Failure to Obtain and Implement Physician Orders for Immediate Care Upon Admission

Clearwater, Florida Survey Completed on 10-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that two residents received physician orders for their immediate care and necessary services upon admission. Both residents were admitted with a history of diabetes mellitus and required insulin therapy, as indicated by their hospital discharge documentation and medication reconciliation. However, upon admission, there was no documentation that the facility staff reviewed or reconciled the discharge medication list with a provider, nor were appropriate insulin orders entered in a timely manner. In both cases, the residents did not receive their prescribed insulin until several days after admission, and blood glucose monitoring was also delayed. For the first resident, the hospital discharge records indicated ongoing insulin therapy, but the facility did not initiate insulin orders or blood glucose checks upon admission. The resident and their representative reported concerns to the nursing staff about the lack of insulin administration, and a grievance was filed. The facility's records showed that insulin was not administered until two days after admission, and long-acting insulin was not started until four days after admission. The resident's blood glucose was not checked until two days post-admission, at which point it was elevated. The second resident was also admitted with a diagnosis of diabetes and a hospital discharge summary indicating insulin therapy. However, the facility did not enter insulin orders or perform blood glucose checks until two days after admission. The resident's representative informed the admitting nurse about the need for insulin, but the orders were not entered, and the first blood glucose check revealed a significantly elevated level. Interviews with staff revealed confusion regarding the hospital discharge paperwork and a lack of communication with the provider to verify or clarify medication orders. The facility lacked a policy on medication reconciliation or diabetes management, and staff did not consistently follow the admission checklist to ensure proper medication review and provider notification.

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