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The Hospital of the University of Pennsylvania-Cedar Avenue was recently cited for safety violations.

Credit: Sukhmani Kaur

A Penn Medicine hospital was cited for safety violations for the second time in a month — of which one incident resulted in the death of a patient.

Hospital nurses' inability to call a “code blue” — a medical term used to indicate a need for emergency aid for patients experiencing medical emergencies — at the Hospital of University of Pennsylvania-Cedar Avenue in November resulted in the death of a patient, as first reported by The Philadelphia Inquirer. The hospital was again under investigation by the Department of Health and Human Services within weeks after delaying emergency care on a patient’s broken wrist.

Hospital inspectors first flagged the quality-of-care issues at HUP-Cedar in November. Shortly after, the Department of Health and Human Services issued initial reports and released an action plan.

In the first incident on Nov. 3, a patient died on the floor of the hospital’s Behavioral Health Unit after slumping over a walker and then collapsing to the floor. Hospital staff, including nurses and mental health technicians, left the patient alone to get a computer and determine steps for issuing a code blue, according to the final Hospital of the University of Pennsylvania report.

Following a two-day, on-site investigation, state health inspectors issued a severe warning that put the hospital at risk of losing government funding and national accreditation if the identified problems were not corrected immediately, according to the report.

The report stated that the patient’s death could have been preventable if staff had acted more swiftly in beginning CPR and well-versed in code blue protocol — adding that CPR was only started on the patient 10 minutes after their initial collapse.

“We are saddened by the loss of this patient and are fully cooperating with the Centers for Medicare and Medicaid Services (CMS) and the Pennsylvania Department of Health (DOH) in connection with this matter,” a Penn Med spokesperson said to The Daily Pennsylvanian. 

The patient death incident led the state to issue a severe safety warning, with health inspectors placing HUP-Cedar in “immediate jeopardy” until the hospital educated behavioral health staff on code blue protocol.

The sanction was lifted after inspectors verified that hospital leaders had communicated to nurses and mental health technicians the importance of checking vital signs when a patient falls.

In the second incident on Nov. 20, another patient was admitted to the behavioral health unit with swelling and extreme pain in their thumb, according to The Inquirer.

The x-ray of the patient’s thumb showed a fracture, but the results were not given to a doctor in a timely fashion — causing the broken bone to not be splinted until four days later after the hospital’s rapid response team was called into the patient’s room.

State inspectors referred to the four-day wait as an “unacceptable delay,” as further delay in emergency care could have resulted in increased injury and risk of death, according to the Inquirer

Hospital leaders investigated both incidents internally, citing “diagnostic overshadowing” — in which staff may wrongly assume that patient complaints of pain pertain to a psychiatric condition instead of a medical one — as a possible reason for underestimating the threat because the incidents occurred on the behavioral health floor. 

A 225-page state inspection report printed on Dec. 26 elaborated on the incident and how the Hospital of the University of Pennsylvania system would improve education on how to respond swiftly and efficiently to emergency medical cases.

“Patient safety is an essential cornerstone of care across Penn Medicine," a Penn Med spokesperson said. "Our plan of correction demonstrates how seriously we take this commitment."

HUP-Cedar administrators plan to train all nursing staff by Feb. 2 on diagnostic overshadowing and the importance of effective and prompt physical examinations. Behavioral health staff training will include how to follow protocol for requesting a surgical consultant and how to seek a specialist when needed.