The incident drew one of the state's harshest warnings, immediate jeopardy.
A disoriented nursing home resident in need of urgent medical care walked out of Thomas Jefferson University Hospital’s emergency department without anyone noticing for hours, because staff failed to routinely check on him.
State inspectors levied an immediate jeopardy warning, a sign of potentially life-threatening safety problems, during an investigation on Jan. 26. Sanctions were lifted hours later, after Jefferson administrators provided a plan to address urgent safety concerns, including adding another nurse to the emergency department to help triage patients.
He was triaged as a Level 3, meaning his condition was urgent and could progress to a serious problem requiring emergency action. Level 3 patients must be reassessed at least every two hours, according to the hospital’s policies.Inspectors found that staff didn’t document any checks on the man or make any any updates to his patient record after the blood sugar test.
The hospital reported him missing to police around 9:30 p.m. that night, according to police reports. Police say the man was found the next day, when he returned to the hospital.In response to the state’s citation, Jefferson determined that any patients arriving by ambulance with an altered mental state should be taken to an internal waiting room, where they could be watched more closely and couldn’t walk out unnoticed.
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