Failure to Obtain Required Signature on MOST Form for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to ensure a Medical Orders for Scope of Treatment (MOST) form was properly completed and validated for one resident reviewed for advance directives. The resident, who had dementia and severely impaired cognitive skills for daily decision-making, was rarely or never understood and had both short- and long-term memory problems, and had a designated Resident Representative. A MOST form dated 10/6/25 documented DNR status, comfort measures, antibiotics if indicated, IV fluids for a defined trial period, and no feeding tube. The form stated it had been discussed with and agreed to by an individual with an established relationship with the patient who could reliably convey the patient’s wishes, and it was signed by an NP. However, the form did not identify the name of the individual with whom it was discussed, and the patient or representative signature section at the bottom of the form was blank. Interviews revealed multiple staff were aware that a MOST form must be signed by the resident and/or Resident Representative to be valid, including Medical Records, the Medical Director, the DON, and the Administrator, all of whom confirmed that this resident’s MOST form was not valid due to the missing representative signature. Medical Records staff stated she was responsible for reviewing completed MOST forms for all required dates and signatures before scanning them into the electronic record and placing the hard copy in the code book, and acknowledged she missed that this resident’s form lacked the Resident Representative’s signature. The Social Worker reported she audited MOST forms mainly to see who had a form, and was unsure if an unsigned form was valid. The NP who completed the form stated she was not aware that the resident/representative signature was required, misinterpreting the language above the signature box as making the signature optional, and did not document the name of the person with whom the form was discussed or obtain a witness signature for a telephone review. The Administrator and Medical Director both indicated that, given the resident’s cognitive status, the Resident Representative’s signature was required and that, if completed by phone, the form should document the representative’s name, indicate telephone review, and include two witness signatures.
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