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Six months of inspections at Jefferson Einstein Montgomery Hospital: November 2023 to April

The Jefferson Health hospital was cited for failing to protect an adult patient from suspected neglect at home.

Inspectors visited Jefferson Einstein Montgomery Hospital three times between October and March to investigate potential safety problems.
Inspectors visited Jefferson Einstein Montgomery Hospital three times between October and March to investigate potential safety problems.Read moreAnton Klusener/ Staff illustration/ Getty Images

Jefferson Einstein Montgomery Hospital was cited in March by state health inspectors for failing to protect a patient admitted to the hospital repeatedly from suspected abuse and neglect occurring at home.

The incident was one of three times inspectors visited the hospital in East Norriton to investigate potential safety violations between November 2023 and April.

Here’s a look at the publicly available details:

  1. Mar. 13: Inspectors found the hospital had not appropriately reported concerns of abuse at home involving a patient who did not talk and was bed-bound. This patient was admitted to the hospital three times between November and January, and discharged to family each time. Nurses filed an abuse and neglect report Dec. 9, during the patient’s second stay, noting the patient was disheveled, malnourished, dehydrated, and had matted hair. The patient had an old urinary catheter filled with foul-smelling urine and pus, and a feeding tube that was crusted with discharge. The patient was admitted to the hospital a fourth time, at the end of January, unresponsive and with a large wound on their hip. Inspectors found that case workers had not told doctors or outside case managers about the suspected neglect. The hospital’s manager of case management met with all staff involved in the patient’s care to to prevent a repeat incident. Case workers and social workers were re-trained on discharge planning and abuse reporting. The hospital agreed to audit cases to ensure compliance.

  2. Mar. 6: Inspectors investigated a complaint but found the hospital was in compliance. Complaint details are not made public when inspectors determine it was unfounded.

  3. Dec. 21: Inspectors found the hospital in compliance with requirements in a follow-up visit stemming from a previous staffing violation. In September 2023, the hospital was cited for not having enough nurses in the emergency department — 42 nurses on a day when there should have been 50. Inspectors found the hospital had not made enough effort to fill the openings. The hospital established a new system for posting staffing shortages so that nurses can volunteer for overtime or nurses from a floater pool can be assigned.