Patient dies at Eagleville Hospital detox unit, state records show

Eagleville Hospital staff did not adequately check on a patient who died while detoxing from drugs at the Montgomery County addiction treatment facility last fall, according to state records.

Withdrawal from some substances, including alcohol and benzodiazepines, can be fatal, and Eagleville offers “medically monitored and medically supervised detoxification” to allow people who are physically dependent on certain drugs to safely withdraw from them, according to the facility’s website.

Staff are responsible for checking on patients in the detox unit every 30 minutes. During each check, a staff member must enter the patient’s room, make direct visual contact, and talk to them briefly. If a patient is sleeping, staff must check whether their face and chest are moving.

Staff did not follow that protocol and failed to routinely monitor a patient being treated in a detox unit in October. The patient was later found unresponsive, according to a state inspection report released last month.

The incident briefly drew one of the state’s most serious rebukes, an immediate jeopardy citation, which indicates serious safety problems that could put patients’ lives at risk. State inspectors removed Eagleville from immediate jeopardy within 24 hours, after the hospital submitted a plan for improvement.

Security footage reviewed by state investigators showed a patient at one of the facility’s detox centers enter their room around 2:30 p.m. A staff member stopped outside the patient’s doorway at 5 p.m., but never entered.

The staff member returned a half hour later, this time entering the patient’s room. A minute later, the staff member left to find another coworker, and both went back into the room.

The patient was found unresponsive in their bed without a pulse, according to notes from a nurse on duty that evening.

Staff performed CPR and twice administered naloxone, the opioid overdose-reversing drug, but the patient remained unresponsive. Police and paramedics also responded to the hospital to “continue life-saving measures,” state investigators found, but eventually discontinued them.

The report did not say what caused the patient’s death. The report also did not include details about the patient, such as gender, age, and what specifically they were being treated for.

But according to the state investigation, the staff assigned to check on the patient “did not follow established facility policy and procedures” and, during their 5 p.m. rounds, only checked on the patient from the doorway of their room.

A technician “directly involved in the missed round” was put on administrative leave, but was reinstated to her position, hospital leaders told state investigators. An internal investigation by the hospital showed the tech had been distracted by other activity on the ward, which administrators described as a “human error,” according to the state report.

The hospital said the technician would receive additional training on rounds. Administrators also pledged to train all staff on rounding procedures and to have clinical supervisors observe rounds across the hospital for a month.

In a statement, Eagleville Hospital leadership said that they were “deeply saddened” by the patient’s death. They declined to comment on the specifics of the case, but said they are working closely with the Pennsylvania Department of Health to correct problems identified during the inspection.

“Our staff values each individual patient and works diligently to support their return to a sustained and successful recovery,” a statement from Eagleville executive assistant Tracy Ely said.