Pottstown Hospital Delayed Adverse Reports

By Walter F. Roche Jr.

Officials of the Pottstown Hospital failed to promptly report adverse and serious events including an assault by a patient which wasn't reported for a month.
The delayed reporting was uncovered during an annual licensure survey by the state Health Department in mid-July.
Citing multiple violations of the state Availability and Reduction of Error Act, the report cites two cases in which there were complications following surgery or an invasive procedure. The two cases came in June and July.
The serious events are supposed to be reported within 24 hours of their discovery, the report notes. An assault by a patient that occurred on May 6 was not reported to the state until June 7, the state surveyors reported.
Pottstown, a 219 bed facility, is owned by Tower Health, a financially troubled company which has been actively trying to sell off hospitals it purchased from Community Health Systems in 2017.
Other delayed reports included a fall which occurred on April 9 but wasn't reported until April 12. An EKG that was mislabeled on March 28 was not reported until April 9. A patient elopement on April 30 was not reported until May 30.
In another citation, surveyors reported that hospital records showed a patient was kept in the emergency room for more than six hours resulting in an "infrastructure failure." Two cases involving blood transfusions were cited in the report due to the failure of hospital to follow established procedures.
In one case hospital employees failed to check for vital signs 15 minutes after a transfusion was initiated. In the second case the blood flow was not increased after 15 minutes as required under hospital procedures.
In its plan of correction the hospital said it had established a procedure to ensure adverse events were properly reported. Adverse events will also be reported to the patient safety committee.
The plan calls for re-education of staff on proper blood transfusion proedures and establishment of an audit system to ensure future complaince. The hospital also promised to develop a labeling system to ensure surgical instruments can be tracked back to a particular patient in the event of an adverse event.
Tower Health did not respond to requests for comment.
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