Patapsco Healthcare: Discharge Documentation Failures - MD
The resident at Patapsco Healthcare had a sacral wound that had gotten worse. The family member asked a nurse to send the resident to the emergency room. The nurse said she had to call the physician first. So the family member picked up the phone, called 911, and had the resident transported to the hospital, where the resident was admitted for wound surgery.
That was October 26, 2024. Federal inspectors arrived at Patapsco Healthcare nearly a year later, on September 11, 2025, following a complaint. What they found in the medical record was almost nothing.
The resident, identified in inspection records only as Resident 30, had been admitted to the facility in February 2024 with complex medical conditions, including pressure wounds. The transfer to the hospital in October came after eight months at the facility. Inspectors reviewed the closed medical record and found two brief nursing notes. One, timestamped 2:01 PM on October 26, recorded that the resident requested to go out by 911 for wound assessment. A second note, at 10:42 PM the same night, noted that the outgoing nurse sent the resident to the hospital for wound evaluation.
That was it.
There was no documentation showing the resident's condition had been assessed before the transfer. There was no record that the physician had been notified of the resident's request to go to the hospital, or of the resident's status, or of the fact that the resident ultimately left by ambulance. No summary of the resident's condition was prepared for the receiving hospital. Nothing in the record showed that the resident or the resident's representative had been told in writing about the transfer or the reasons for it.
The facility also failed to provide a written bed-hold notice at the time of transfer, which would have told the resident how long the facility would hold the bed while the resident was hospitalized. There was no such notice in the record.
After the resident was admitted to the hospital and subsequently discharged from the facility entirely, the resident's physician was required to complete a discharge summary capturing the resident's stay. Inspectors found no evidence one was ever written.
The MDS discharge assessment, dated October 27, 2024, recorded the transfer as unplanned. It listed the destination as an acute hospital. Beyond that, the formal record of what happened to Resident 30 during eight months at Patapsco Healthcare, and why the resident left the way they did, exists in two brief nursing notes and a checkbox.
Inspectors discussed the findings with the Nursing Home Administrator on September 10, 2025. The administrator acknowledged the concerns and offered no further comment.
The violation was cited at a level of minimal harm or potential for actual harm. But the inspection report describes something the paperwork itself cannot fully capture: a resident whose wound had worsened to the point of requiring surgery, whose family felt they had no option but to call 911, and whose departure from the facility generated almost no formal record of what had occurred or why.
The hospital that received Resident 30 had no transfer summary to work from. No written account of the wound's history, the medications in use, the care that had been provided, or the circumstances that led to the 911 call. Whatever the receiving team knew about this patient, they did not learn it from Patapsco Healthcare.
The resident was admitted for wound surgery and did not return to the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Patapsco Healthcare from 2025-09-11 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
PATAPSCO HEALTHCARE in RANDALLSTOWN, MD was cited for violations during a health inspection on September 11, 2025.
The resident at Patapsco Healthcare had a sacral wound that had gotten worse.
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.