Autumn Lake Summit Park: Wrong Blood Draw - MD
The mistake occurred on December 9, 2024, when a laboratory worker entered Resident #44's room and collected blood samples intended for someone else. The error went undetected until a family member visiting later that day noticed gauze and tape on the resident's hand.
The visitor asked the resident's roommate what had happened. The roommate explained that a lab technician had come into their room and mistakenly drew Resident #44's blood.
When the family member questioned facility staff about the incident, they were unaware it had occurred.
The family filed a grievance with the nursing home. Eight months later, federal inspectors reviewing complaints against the facility discovered the case during their annual survey in August 2025.
The facility's own investigation substantiated the error. According to the Assistant Director of Nursing, who confirmed the incident to inspectors on August 19, the lab mistake happened specifically because Resident #44 was not wearing an identification wristband at the time.
Federal inspectors reviewed 28 complaints during their survey and found this case represented a failure to maintain accident-free conditions and adequate supervision. The inspection report noted the facility "failed to ensure the resident had an identification wrist band on which led to the wrong resident having their blood drawn."
The grievance filed by the family was processed in December 2024, according to facility records reviewed by inspectors. The nursing home's investigation confirmed that the lab error occurred and that the resident lacked proper identification at the time of the mistake.
The Assistant Director of Nursing told inspectors she became aware of the concern following the facility's investigation into the incident. She confirmed that the absence of an identification wristband directly caused the wrong resident's blood to be drawn.
Inspection records show the complaint was logged as #330059 and reviewed by federal surveyors on August 13, 2025. The complainant was interviewed that same day at 12:15 PM, providing details about discovering the error through the resident's roommate rather than facility staff.
The case highlights identification protocol failures at the 215326-licensed facility. Federal nursing home regulations require proper resident identification to prevent medical errors, particularly during procedures like blood draws where patient safety depends on accurate identification.
The inspection classified the violation as causing "minimal harm or potential for actual harm" and affecting "few" residents. However, the incident demonstrates how basic safety protocols can fail when identification systems break down.
The family member who discovered the error had to learn about it from another resident rather than nursing home staff, suggesting the facility's incident reporting and communication systems also failed in this case.
Laboratory procedures in nursing homes typically require multiple identification checks before drawing blood or administering medications. The absence of a wristband removes a critical safety barrier designed to prevent exactly this type of medical error.
The timing of the discovery also raises questions about the facility's monitoring systems. The blood draw occurred during a routine visit, but staff remained unaware of the mistake until the family member raised concerns.
Federal inspectors found the facility violated regulations requiring nursing homes to maintain accident-free environments and provide adequate supervision to prevent medical errors. The violation was documented under federal tag F 0689, which covers accident hazards and supervision requirements.
The inspection report does not indicate whether the wrong blood draw caused any medical complications for Resident #44 or affected the resident who should have received the lab work. It also doesn't specify what type of blood tests were involved or whether results were mixed up between patients.
The case was resolved through the facility's grievance process, but the inspection report doesn't detail what corrective actions the nursing home implemented to prevent similar identification errors.
The incident occurred nearly eight months before federal inspectors discovered it during their complaint review process, suggesting the error might have remained internal to the facility's grievance system without the annual survey examination.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare At Summit Park from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AUTUMN LAKE HEALTHCARE AT SUMMIT PARK in CATONSVILLE, MD was cited for violations during a health inspection on August 27, 2025.
The mistake occurred on December 9, 2024, when a laboratory worker entered Resident #44's room and collected blood samples intended for someone else.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.