Nine months of inspections at Thomas Jefferson University Hospital: March to November 2024
The hospital was cited for failing to properly monitor a patient being treated for septic shock.
Thomas Jefferson University Hospital was cited by the Pennsylvania Department of Health for a paperwork violation after nurses failed to properly document cardiac monitoring for a patient who was being treated for septic shock.
The incident was one of a dozen times state health inspectors visited Jefferson Health’s flagship medical center to investigate potential safety problems between March and November 2024.
Here’s a look at the publicly available details:
May 8: Inspectors followed up on a previous complaint in January 2024, regarding a patient who went missing from the emergency department, and found the hospital was in compliance.
May 30: 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.
Aug. 13: Inspectors came to investigate a complaint but found the hospital was in compliance.
Aug. 29: Inspectors came to investigate two complaints but found the hospital was in compliance.
Aug. 9: Inspectors cited the hospital for failing to properly document heart rhythm strips for a patient with septic shock who required cardiac monitoring. Administrators retrained nurses on cardiac monitoring protocol and assigned float nurses to check that monitoring was being documented correctly.
Sept. 27: Inspectors came to investigate a complaint but found the hospital was in compliance.
Sept. 25: Inspectors cited the hospital for beginning a compounding pharmacy service at its main campus and Jefferson Methodist Hospital, which operates under the same license, before receiving formal health department approval. Administrators agreed to notify the health department of new services at least 60 days in advance, as required by state law, and retrained staff on occupancy regulations.
Oct. 9: Inspectors came to investigate two complaints but found the hospital was in compliance.
Oct. 4: Inspectors conducted a mental health survey and found the hospital was in compliance.
Oct. 25: Inspectors conducted a special monitoring survey at Jefferson’s outpatient rehabilitation center on Cecil B. Moore Avenue and found the facility was in compliance.
Oct. 29: Inspectors came to investigate a complaint but found the hospital was in compliance.
Oct. 23: Inspectors followed up on the September citation regarding the compounding pharmacy and found the hospital was in compliance.
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.
