A year of inspections at Jefferson Health Northeast: July 2024 - June 2025
Jefferson Frankford Hospital was cited for failing to check on two patients in restraints every 15 minutes.
Jefferson Frankford Hospital was cited in June by the Pennsylvania Department of Health for failing to check on patients in violent restraints every 15 minutes, as required by state law.
The incident was one of more than two dozen times the health department investigated potential safety incidents at one of three Jefferson Health Northeast hospitals.
The health system’s Frankford, Torresdale, and Bucks hospitals operate under a shared license, Jefferson Health Northeast. Publicly available reports do not always indicate which hospital inspectors visited.
Here’s a look at the publicly available details:
July 23, 2024: Inspectors came to investigate a complaint but found the hospital was in compliance. Complaint details are not made public when inspectors determine it was unfounded.
July 25: Inspectors came to investigate a complaint but found the hospital was in compliance.
Sept. 4: Inspectors confirmed a safety incident at Torresdale Hospital, but the hospital had fixed the problem before inspectors arrived. The hospital’s correction plan included asking the Board of Trustees to review the event and taking “corrective action steps” for staff involved in the incident.
Sept. 13: Inspectors came to investigate a complaint but found the hospital was in compliance.
Oct. 15: Inspectors came to investigate a complaint but found the hospital was in compliance.
Oct. 22: Inspectors came to investigate a complaint but found the hospital was in compliance.
Nov. 15: Inspectors came to investigate a complaint but found the hospital was in compliance.
Nov. 26: Inspectors cited Jefferson Health Northeast for not following a clear policy for transferring patients from an outpatient clinic to the emergency department. A patient came to the emergency department in August 2023 because their oxygen saturation level had dropped below 80% during a visit to an outpatient doctor’s office earlier that day. (Oxygen saturation levels below 88% are considered dangerous and require immediate attention, according to the Cleveland Clinic.) The doctor had stopped a pulmonary test to evaluate lung function when the patient’s oxygen level dropped, but did not tell them to see emergency care or initiate a transfer to the hospital, according to the report, which does not specify which of the three hospitals was involved in the incident. Administrators created a new policy for evaluating urgent medical needs that may require transfer from an outpatient office to the hospital, including protocol for documenting transfers.
Dec. 18: Inspectors came to investigate a complaint but found the hospital was in compliance.
Jan. 15, 2025: Inspectors came to investigate a complaint but found the hospital was in compliance.
Jan. 22: Inspectors came to investigate a complaint but found the hospital was in compliance.
Jan. 24: Inspectors came to investigate a complaint but found the hospital was in compliance.
Jan. 30: Inspectors came to investigate a complaint but found the hospital was in compliance.
Feb. 6: Inspectors came to investigate a complaint but found the hospital was in compliance.
Feb. 10: Inspectors came to investigate a complaint but found the hospital was in compliance.
Feb. 10: Inspectors came for a special monitoring survey at Frankford Hospital and found that a problem with morgue policies had been resolved before inspectors arrived. The hospital’s correction plan included retraining staff on how to handle patients who have died, morgue duties, protocol for notifying patient families, and policies for working with funeral homes to transfer patient remains.
March 4: Inspectors came to investigate a complaint but found the hospital was in compliance.
March 6: Inspectors came to investigate a complaint but found the hospital was in compliance.
March 14: Inspectors investigated two separate complaints but found the hospital was in compliance.
March 20: Inspectors came to investigate a complaint but found the hospital was in compliance.
March 21: Inspectors came to investigate a complaint but found the hospital was in compliance.
March 24: Inspectors came to investigate a complaint but found the hospital was in compliance.
April 11: Inspectors came to investigate a complaint but found the hospital was in compliance.
May 28: Inspectors came to investigate a complaint but found the hospital was in compliance.
June 12: The hospital was cited for failing to check on two patients in restraints for acting violently every 15 minutes, as required by state law. In August 2024, a patient was physically restrained for acting violently at 1:15 p.m. and not checked on again until 3 p.m. The patient remained in restraints until at least 7 p.m., with only two checks at 5 p.m. and 6:30 p.m., according to records reviewed by inspectors. The same month, a second patient was restrained from about 8 p.m. to 10:30 p.m. without being checked on every 15 minutes. The hospital retrained staff on protocol for checking on patients with violent restraints every 15 minutes and documenting their check in a restraint log.
June 26: Inspectors came to investigate a complaint but found the hospital was in compliance.