Federal inspectors found Citizens Care and Rehabilitation Center of Frederick failed to follow required procedures for voiding MOLST forms when updating a resident's treatment preferences. The Maryland Orders for Life Sustaining Treatment documents specify whether residents want cardiopulmonary resuscitation and other life-sustaining interventions.
The inspection revealed Resident #6's electronic medical record contained five scanned copies of voided MOLST forms alongside the original, un-voided versions of those same documents. The forms spanned multiple dates and showed changing preferences about CPR decisions.
The resident's treatment wishes evolved over time. Early forms indicated "Attempt CPR - per resident" and later "Attempt CPR per Surrogate decision maker." Subsequent versions shifted to "No CPR option A2 with changes to page 2," then "No CPR Option B with changes to Page 2," and finally "No CPR, Option B with changes to Page 2."
Each time preferences changed, facility staff should have voided the previous form completely. Maryland MOLST instructions require specific steps: the physician, nurse practitioner, or physician assistant must draw a diagonal line through the sheet, write "VOID" in large letters across the page, and sign and date below the line.
The facility kept the voided copies but also maintained the original, un-voided versions in the electronic system. This created a medical record containing both active and inactive versions of the same life-sustaining treatment orders.
When inspectors interviewed the facility administrator, she acknowledged the problem existed in the electronic medical record system. She explained that the paper record contained the original MOLST forms with proper voiding procedures completed on all but the most recent version.
The administrator confirmed that staff had followed voiding procedures on the physical documents. However, the electronic scanning process had captured and preserved both the properly voided forms and the original, un-voided versions of those same documents.
Federal regulations require nursing homes to maintain medical records according to accepted professional standards. The MOLST system depends on clear documentation of current treatment preferences, with outdated forms properly voided to prevent confusion during medical emergencies.
A corporate nurse was notified about the record-keeping violations during the inspection. The facility's dual documentation system created the potential for medical staff to reference outdated treatment preferences during critical situations.
The inspection classified this as a minimal harm violation affecting few residents. However, MOLST forms carry legal weight as physician orders that emergency responders and medical staff must follow during life-threatening situations.
Maryland's MOLST program allows patients to document their wishes about specific medical interventions. The forms travel with patients between healthcare settings and guide treatment decisions when individuals cannot communicate their preferences.
Proper voiding procedures ensure medical staff can quickly identify current treatment preferences without confusion from outdated orders. The diagonal line, "VOID" marking, and physician signature create a clear visual indication that previous orders no longer apply.
Citizens Care's electronic medical record system undermined this clarity by preserving both voided and active versions of the same documents. Medical staff accessing the electronic record would encounter multiple MOLST forms for the same resident without clear indication of which orders remained valid.
The facility's paper records maintained proper voiding procedures, but the electronic system created a secondary problem. Nursing homes increasingly rely on electronic medical records for quick access to patient information during emergencies and routine care.
The inspection found this record-keeping failure affected at least one of three residents reviewed for quality of care violations. The scope suggests similar problems may exist in other residents' electronic medical records.
Federal inspectors documented the violation under regulations governing medical record maintenance and resident-identifiable information protection. The facility must ensure all medical records, whether paper or electronic, follow accepted professional standards.
The corporate nurse's involvement indicates Citizens Care recognized the need for system-wide corrections to prevent similar documentation problems. However, the inspection report does not detail what corrective measures the facility planned to implement.
Resident #6's changing treatment preferences reflected the evolving nature of end-of-life care decisions. The multiple MOLST forms showed how individuals may reconsider their wishes about life-sustaining interventions over time, making proper record-keeping essential for honoring those decisions.
The violation highlights broader challenges nursing homes face when transitioning between paper and electronic medical record systems. Proper staff training and system design become critical for maintaining regulatory compliance while preserving the integrity of life-sustaining treatment orders.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Citizens Care and Rehabilitation Center of Frederi from 2025-10-16 including all violations, facility responses, and corrective action plans.
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