F0684

G

Failure to Honor MOLST DNR/DNI Orders and Misapplication of BP Parameters for Cardiac Medication

Silver Spring, Maryland Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor a resident’s updated end-of-life wishes as documented on a revised Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form. One resident was initially admitted with a MOLST indicating full code status and all life-sustaining treatments. After a subsequent hospitalization and readmission, the attending physician documented an extensive discussion with the resident’s power of attorney and determined that the resident, who lacked capacity to make medical decisions and had multiple serious diagnoses including cerebrovascular accident with residual weakness, atrial fibrillation, diabetes, chronic anemia, gastrostomy tube, and metastatic prostate cancer to bone, was to be DNR/DNI with other measures permitted. A new MOLST form was completed indicating No CPR and Do Not Intubate, but the prior full-code MOLST was not voided by facility staff.

When the resident later experienced a change in condition characterized by vomiting coffee-ground-like material, an LPN notified the on-call physician, obtained an order to transfer the resident to the hospital via 911, and prepared copies of the medical record, including medication orders and the MOLST form, for EMS. The LPN could not recall the specific contents of the MOLST form sent and only identified the resident as a hospital transfer. The attending physician stated they were unaware which MOLST form was sent with the resident. Review of the hospital record showed that the MOLST accompanying the resident was the earlier full-code form, labeled with the resident’s hospital information, and that the updated DNR/DNI MOLST had not been clearly communicated to EMS. As a result, the resident, who had documented DNR/DNI status on the newer MOLST, received CPR and intubation during EMS transport and was subsequently treated in the hospital ICU for 20 days.

A second deficiency concerns the facility’s failure to follow specific physician-ordered blood pressure parameters for administering a cardiac medication to another resident. The physician ordered Lisinopril 10 mg by mouth once daily for hypertension, with instructions to hold the dose if the systolic blood pressure was less than 100 mm Hg. Review of the medication administration records for two months showed that nursing staff withheld multiple doses of Lisinopril on days when the resident’s systolic blood pressure readings were between 106 and 109 mm Hg, all above the ordered hold parameter. In an interview, the LPN who withheld these doses confirmed they were responsible for the omissions and acknowledged that, upon re-reading the physician’s prescribed parameters, the doses should have been administered as ordered.