Failure to Properly Void and Maintain MOLST Forms in Medical Records
Penalty
Summary
Facility staff failed to ensure that all prior Maryland Orders for Life Sustaining Treatment (MOLST) forms in a resident's medical record were properly voided according to MOLST instructions. Review of the electronic medical record (EMR) for one resident revealed the presence of both voided and un-voided copies of multiple MOLST forms for the same dates, in addition to the most recent MOLST form. According to MOLST protocol, when a change is made to any order, the previous form must be voided by drawing a diagonal line through the sheet, writing VOID in large letters, and signing and dating below the line. While the paper record contained voided originals for all but the most recent MOLST, the EMR retained both voided and un-voided versions, which is not in accordance with accepted professional standards for maintaining medical records. The deficiency was identified during a review of the resident's EMR and confirmed through interviews with the facility Administrator and Corporate Nurse. The Administrator acknowledged that the EMR contained both voided and active copies of each MOLST form, despite the paper record being properly maintained. This failure to properly void and manage MOLST forms in the EMR resulted in noncompliance with requirements to safeguard resident-identifiable information and maintain accurate medical records.