Friday, January 19, 2018

Einstein Inspection Report Finally Posted

By Walter F. Roche Jr.

More than six months after a critical inspection, state officials have finally made public a trimmed down hospital inspection report that omits multiple details included in a prior version which state officials now say had been briefly but mistakenly made public.
The now official report on a three day May inspection at the Albert Einstein Medical Center cites the
701 bed facility for failure to properly analyze and implement preventative actions after four patients experienced adverse events.
"The  hospital must measure, analyze and track adverse patient events," the report states.
The official report provides details on two of the cases which resulted in deaths. Details of two other deaths included in a prior version of the report are not included in the official report.
April Hutcheson, spokeswoman for the Pennsylvania Health Department, said the initial report was "not completed and unintentionally posted."
"The report on the site now is correct," she added.
She declined to answer questions about details included in the initial report but omitted from the now official report.
Einstein officials did not respond to requests for comment but the facility did submit a corrective action plan to the state including updating procedures for responding to adverse events. The hospital, however, said it disputed the state's right to access certain internal documents relating to the cases.
The two cases detailed in the official report include a patient admitted to the facility on Aug. 3, 2016 "looking pale and unresponsive." A subsequent entry stated the patient later died from "excessive sedation leading to hypo-ventilation and brain anoxia."
The second case detailed in the final report involved a patient who underwent a colonoscopy on September of 2016 and left "against medical advice."
The patient, according to the report, returned the next day with worsening abdominal pain and eventually passed away.
The report cites Einstein for failing to conduct a root cause analysis, a process designed to find the root cause of an error, on the two cases.
Omitted from the final report were details of the other two cases. One involved a patient who choked on a sandwich and the other a patient who was injured during an esophageal in-tubation.
Both the final and initial reports cited Einstein for refusing to allow state inspectors to interview staff involved in one of the cited cases.

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