Failure to Timely Update and Document Resident's Life-Sustaining Treatment Preferences
Penalty
Summary
The facility failed to update and accurately document a resident's wishes regarding life-sustaining treatment and did not assess the resident's decision-making capacity in a timely manner. The resident, who was their own responsible party, had a Maryland MOLST form indicating a DNR (Do Not Resuscitate) order, but subsequent documentation by staff indicated the resident expressed a desire to attempt CPR and was alert and oriented at that time. Despite this, the MOLST was not updated to reflect the resident's clarified wishes, and there were discrepancies between the resident's expressed preferences and the orders documented in the medical record. Further review revealed that after the resident experienced changes in condition and was transferred to and from the hospital, staff expressed discomfort discussing code status and requested a re-evaluation of the resident's capacity. However, no timely capacity evaluation was completed, and the medical records remained unclear about who the decision maker was during this period. Both the DON and the social worker confirmed these discrepancies and the lack of timely assessment, resulting in unclear and inconsistent documentation of the resident's life-sustaining treatment preferences.