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F0578
B

Failure to Ensure Valid MOLST Form Reflecting Health Care Proxy Signature

Holyoke, Massachusetts Survey Completed on 08-27-2025

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 accurately execute advance directives for one resident with diagnoses of unspecified dementia and mood disturbance. The resident had a Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) form in their clinical record, which was signed by a Registered Nurse following a conversation with the resident's activated Health Care Proxy (HCP). However, the MOLST form did not contain the required signature of the HCP, despite a physician's order indicating that the HCP had been activated and was the designated healthcare decision maker for the resident. Facility policy requires that advance directive forms, such as the MOLST, be completed and signed by the resident or their legal surrogate as permitted by state law, and that these directives be reviewed during quarterly care planning sessions. The Director of Nursing confirmed during interview that the MOLST form was not valid due to the absence of the HCP's signature and acknowledged that a new, properly signed MOLST form should have been completed.

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