Federal inspectors found Crescent Cities Nursing & Rehabilitation Center kept conflicting end-of-life instructions for Resident #15 in September, following a complaint alleging staff had abused the patient. The facility's medical records contained a Maryland Medical Orders for Life-Sustaining Treatment form indicating the resident and guardian chose "No CPR, DNI (do not intubate)" for life-sustaining care.
But the same resident's file also contained a physician's order directing staff to provide "Full Code/CPR." The resident's basic admission care plan repeated this instruction, stating Resident #15 wished to be "Full Code/CPR."
The inspection report reveals no explanation for how both orders existed simultaneously in the same medical record. Such contradictions create dangerous confusion during medical emergencies, when staff must make split-second decisions about whether to attempt resuscitation.
Medical records serve as the official documentation of healthcare decisions and must follow professional standards for accuracy and completeness, according to federal regulations. All entries should be legible and accurate, particularly for life-and-death decisions like resuscitation orders.
The Maryland MOLST form was completed by a hospital physician before the resident's admission to the nursing home. The front page clearly indicated the resident and guardian's wishes for no CPR and no intubation. However, inspectors found the back page of this critical document was never completed.
Despite having this hospital-generated MOLST form on file, facility staff created their own contradictory orders. The physician's order directing "Full Code/CPR" appeared to override the hospital's documentation of the resident and guardian's actual wishes.
The resident's admission care plan compounded the confusion by also indicating a preference for full resuscitation efforts. This created a three-way contradiction within the same medical file, with the MOLST form saying no CPR while two other documents demanded full life-saving measures.
Inspectors noted that advance directive documents were not available for review in the resident's closed medical record. These documents typically provide the clearest indication of a patient's end-of-life preferences and serve as the foundation for medical decision-making.
The conflicting orders emerged during an investigation triggered by allegations that facility staff had abused Resident #15. State surveyors received the complaint and began reviewing the resident's closed medical record as part of their investigation.
The timing suggests the medical record problems may have contributed to or complicated the alleged abuse situation. When healthcare staff cannot determine a resident's actual wishes for medical care, it creates opportunities for inappropriate treatment decisions.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to residents. However, the nature of the violation suggests the potential consequences could have been far more severe during a medical emergency.
Had Resident #15 experienced cardiac arrest or respiratory failure, nursing staff would have faced an impossible decision. The medical record provided no clear guidance about whether to begin CPR, call for emergency intubation, or allow natural death as the resident and guardian had apparently requested.
Such confusion violates basic principles of patient autonomy and informed consent. Residents have the right to make decisions about their own medical care, including the choice to refuse life-sustaining treatment. When facilities maintain contradictory records, they undermine this fundamental right.
The inspection found that Crescent Cities failed to maintain complete and accurate medical records for at least one of the 30 residents reviewed during the complaint survey. The violation affects the facility's ability to provide appropriate care and respect resident wishes during critical moments.
Medical record integrity becomes especially crucial for residents with complex medical conditions or those nearing end of life. Clear documentation prevents confusion among multiple caregivers and ensures continuity of care across shifts and departments.
The Maryland MOLST form represents a standardized approach to documenting end-of-life preferences that travels with patients between healthcare settings. When nursing homes override or contradict these physician-completed forms without clear justification, they disrupt the continuity of care.
Professional standards require healthcare organizations to maintain medical records that accurately reflect patient conditions, treatments, and preferences. The contradictory orders at Crescent Cities suggest systemic problems with record-keeping procedures and oversight.
The incomplete MOLST form adds another layer to the documentation failures. When the back page of such critical documents remains blank, it suggests insufficient attention to detail during the admission process or inadequate staff training on proper procedures.
Nursing homes regularly care for residents with complex advance directive preferences, making accurate record-keeping essential for ethical care delivery. The contradictions found at Crescent Cities could have resulted in unwanted medical interventions or inappropriate withholding of desired care.
The violation occurred at a facility that serves vulnerable residents who depend on staff to honor their healthcare decisions. When medical records contain fundamental contradictions about life-and-death preferences, it represents a breakdown in the most basic aspects of patient care.
State surveyors discovered these problems while investigating allegations of resident abuse, suggesting the medical record failures may be part of broader care quality issues at the facility. The complaint-driven nature of the inspection indicates ongoing concerns about resident treatment and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crescent Cities Nursing & Rehabilitation Center from 2025-09-12 including all violations, facility responses, and corrective action plans.
Additional Resources
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