Ten months of inspections at Roxborough Memorial Hospital: July 2024 - April 2025
The hospital was cited for failing to report suspected abuse of a behavioral health patient.
Roxborough Memorial Hospital was cited by the Pennsylvania Department of Health in April for failing to report a case in which a patient told emergency staff that they had been abused at a behavioral health facility before coming to the hospital.
The incident was among six times health inspectors visited the Philadelphia hospital, which is owned by Prime Healthcare Services, to investigate potential safety problems.
Here’s a look at the publicly available details:
July 9, 2024: Inspectors visited for a mental health survey and cited the hospital for failing to update treatment plans for mental health patients every 30 days. Inspectors found the hospital had not kept treatment plans updated for three of seven patient files reviewed, including a patient with dementia and another patient with schizophrenia. The hospital retrained staff on requirements for reviewing treatment plans, and agreed to monitor cases to ensure they were being updated on time through its electronic health record.
Jan. 27: 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.
Jan. 31: 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.
March 31: Inspectors came to investigate a complaint but found the hospital was in compliance.
April 25: Inspectors investigated a complaint regarding a patient who had been transferred to Roxborough in May 2024 from a behavioral health facility. The patient reported to hospital staff that a nurse at the behavioral health facility had pulled her arm so hard she thought it had become dislocated. The patient’s complaint, including that she felt unsafe at the behavioral health facility, was documented in nurse notes, but never reported to the state. The woman was transferred back to the behavioral health facility a day later. Hospitals are mandated reporters, meaning they are required to report instances of suspected abuse. Staff were retrained on abuse reporting requirements, and administrators agreed to audit patient charts.
Pennsylvania Department of Health routinely inspects hospitals to ensure the facility is safe for patients and that staff are following all safety protocols. Inspectors may also visit when a hospital staff member or patient files a complaint.
Not all safety violations spark an on-site investigation from inspectors. Hospitals are required to self-report the most serious safety violations and often work directly with the state to address them. Complaint details are not made public when inspectors determine it was unfounded.
The Inquirer tracks publicly available hospital reports related to a complaint, special monitoring, and general safety inspections. The Inquirer does not track inspections for new equipment or occupancy surveys, unless problems are identified.
Inspection reports are publicly available online and are released 40 days after the report is completed.
The Inquirer is publishing roundups of state inspection reports for Pa. hospitals in our coverage area.
