Federal inspectors found that Hagerstown Healthcare Center failed to maintain accurate medical records by allowing a resident to have several unvoided Maryland Orders for Life Sustaining Treatment forms simultaneously. The MOLST documents guide critical decisions about cardiopulmonary resuscitation and other emergency interventions.
Maryland MOLST protocols require only one active form per patient. When treatment preferences change, medical staff must void the old form by drawing a diagonal line through it, writing "VOID" in large letters, and signing with a date. A new form then replaces the voided one.
But Resident #3's electronic file told a different story.
Inspectors reviewing the medical record on October 22 discovered a pattern spanning three months. The resident had an unvoided MOLST dated July 7, plus a copy of that same July 7 form that had been voided on July 17. Then came another unvoided MOLST from July 17, alongside a voided version of that form dated September 22.
The confusion continued. A September 22 MOLST remained unvoided in the file, while a voided copy showed it had been canceled on October 14. The most recent unvoided form was dated October 14, but that document had also been voided the very next day, October 15.
Each time staff created a new MOLST, they properly voided the previous version. But they kept uploading copies of both the voided and unvoided forms into the same electronic record.
Staff #5, the facility's social worker, explained the process during an October 23 interview. When a new MOLST was created, the old one would be voided, and both documents would be scanned into the electronic medical record system.
The social worker said copies of original, unvoided forms stayed in the resident's file because "medical records were not to be deleted." Having both voided and unvoided MOLST forms in the electronic record "showed a trail," according to the staff member.
But Maryland MOLST instructions specify that voided forms should remain in medical records while making clear that only one unvoided form should be active. The facility's approach created multiple active orders simultaneously.
MOLST forms carry legal weight in medical emergencies. The portable documents travel with patients between facilities and guide paramedics, hospital staff, and nursing home workers during life-threatening situations. When multiple unvoided forms exist, medical staff cannot determine which treatment preferences actually reflect the resident's current wishes.
The orders cover fundamental end-of-life decisions. Residents and their families work with physicians to specify whether they want CPR attempted if their heart stops, whether they want mechanical ventilation if they cannot breathe independently, and what level of medical intervention they prefer during health crises.
A physician, nurse practitioner, or physician assistant must sign each MOLST form. Nurses can take verbal orders to void forms, but the voiding process requires specific steps to prevent exactly the kind of confusion inspectors found at Hagerstown Healthcare.
During the inspection, federal surveyors explained their concerns to both the nursing home administrator and the social worker. The officials acknowledged the problems with maintaining multiple unvoided MOLST forms for the same resident but offered no additional comments about how the facility would address the record-keeping failures.
The violation affected one of four residents whose records inspectors reviewed during the complaint survey. Federal regulators classified the harm level as minimal, indicating the record-keeping problems had not yet resulted in actual injury to residents.
However, the potential consequences extend beyond paperwork errors. Emergency medical situations require split-second decisions, and conflicting treatment orders could delay critical care or result in interventions that contradict a resident's actual preferences.
Maryland's MOLST system was designed to ensure clarity during medical crises. The standardized forms eliminate guesswork about patient wishes and provide legal protection for medical staff who follow properly executed orders.
Hagerstown Healthcare's electronic filing system undermined those protections by creating ambiguity where state protocols demanded precision. The facility's approach of maintaining "trails" in medical records conflicted with the fundamental requirement that residents have one clear, active set of treatment instructions.
The inspection occurred in response to a complaint, though federal records do not specify the nature of the original concern that prompted the survey.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hagerstown Healthcare Center from 2025-10-23 including all violations, facility responses, and corrective action plans.