Failure to Honor Residents' Advance Directives for CPR Due to Inadequate MOLST Management
Penalty
Summary
The facility failed to have a process in place to ensure that residents' choices regarding cardiopulmonary resuscitation (CPR), as documented in their Maryland Orders for Life-Sustaining Treatment (MOLST) forms, were honored. This deficiency was identified through record review and staff interviews, which revealed that staff were unclear about where to locate the active MOLST forms in the electronic medical record. Multiple staff members reported different methods for determining code status, including checking the information bar, reviewing uploaded documents, or referencing daily assignment sheets. However, there was no standardized procedure, and it was noted that retrieving the correct information could be time-consuming. For one resident, two active MOLST forms were found in the medical record: one indicating full code status and another, more recent, indicating no CPR. The older form was not voided, and conflicting physician orders were present in the system. When the resident was found unresponsive, CPR was initiated by staff, and it was only after EMS arrived and reviewed the paperwork that the resident's wish for no CPR was discovered. Staff failed to document the time CPR was started, and interviews revealed a lack of recall about the incident and confusion regarding the correct code status at the time of the event. An audit following the incident identified other residents with multiple active MOLST forms and conflicting code status orders. A similar incident occurred with another resident who had an active MOLST indicating no CPR, but this document was not uploaded into the record until after a conflicting full code order had been entered and remained active. When the resident coded, CPR was initiated despite the resident's documented wishes. Staff interviews and review of statements failed to clarify where the nurse checked for code status before starting CPR, and it was confirmed that two active MOLST forms were present in the record at the time. These failures led to the declaration of Immediate Jeopardy due to the facility's inability to ensure residents' advance directives were followed.
Removal Plan
- The facility completed audit of all MOLST forms and code status orders to ensure they matched.
- Any discrepancies identified were corrected upon discovery.
- The audit was completed by the Assistant Director of Nursing.
- All clinical nursing staff in the facility, including agency staff, were educated on ensuring that when a code event occurs, they are to look in Point Click Care under documents and filter for category MOLST for the active MOLST.
- Any staff not available will be educated prior to beginning their next scheduled shift to include active agency staff.