HUP Cedar waited four days to splint a patient’s broken wrist, state inspectors find

A patient who came to the Hospital of the University of Pennsylvania-Cedar Avenue unable to move the thumb on their swollen, lacerated hand waited four days for doctors to splint the broken bone.

An X-ray taken shortly after the patient arrived on Nov. 20 confirmed a fractured wrist, but records show it wasn’t splinted for days — and only then after the hospital’s emergency response team was called to the behavioral health unit to help the patient, inspectors found.

State inspectors cited HUP-Cedar for an “unacceptable delay” in emergency care, noting it could have led to further injury and increased the patient’s risk of death in an inspection report released earlier this month.

It was the second time in weeks that hospital inspectors have flagged a serious quality-of-care issue at the West Philadelphia hospital, an outpost of Penn’s flagship hospital. A patient collapsed on the floor and died in early November at HUP-Cedar, which specializes in treating mental health crises and addiction, because nurses and techs on the behavioral health unit didn’t know what to do. The team didn’t start CPR for 10 minutes.

Leaders discussed how the incidents possibly involved “diagnostic overshadowing,” which happens when doctors and nurses attribute a patient’s complaints of physical pain to a psychiatric illness. It can result in missed warnings of serious health concerns.

Both times, hospital administrators retrained staff on how to respond to emergencies. Patient safety is Penn’s top priority, said Regina Cunningham, CEO of the Hospital of the University of Pennsylvania, in a statement to The Inquirer.

“We learn from these events and use our findings to benefit care for all patients,” she said.

The back-to-back incidents are an uncommon rebuke for Penn, an internationally renowned academic medical center and hospital system.

Penn took over the former Mercy Hospital on the brink of closure in 2021, and last year announced plans to realign all of Penn’s behavioral health services around a new crisis response center, which opened in September. HUP-Cedar provides emergency mental health services, as well as specialized psychiatric services. Penn has committed to investing $100 million for the building’s lease, facility upgrades, new equipment and reopening the crisis response center.

HUP-Cedar’s 31 inpatient psychiatric beds and 16 detoxification beds fill a need for more intensive services for mental health patients, with demand for such services on the rise since the COVID-19 pandemic.

“Penn is telegraphing that they want to be on the cutting edge of this crisis,” said Kelsey Leon, a clinical researcher who studies harm reduction at Penn and a member of Philly Coalition for Dignity in Treatment, which advocates for access to health services for people experiencing addiction.

After the state citations, Penn must do more to prepare staff to work with patients who have complex combinations of chronic health conditions, and behavioral or mental health problems, “if Penn really plans to make HUP-Cedar a hub for mental health,” she said. The Philly Coalition has been meeting with HUP-Cedar executives to talk about how to improve services.

“My concern is that there are more instances, and this is just going to continue to exacerbate the medical issues and alienate patients,” she said.

HUP-Cedar’s latest citation found that staff failed to provide timely care to a patient who came through the hospital’s emergency department.

The patient arrived around 6:30 a.m. on Nov. 20 with cuts on their right hand and left ear. The report does not include details about the patient, such as gender, age, and why they were admitted to the hospital’s behavioral health unit. It also does not say who filed the complaint.

Nurses noted the patient couldn’t move their thumb. An X-ray showed a fracture. The results were never given to a doctor, staff told inspectors.

Two days later, nurses observed the patient was experiencing “10 out of 10 pain,” swelling and limited mobility, the report says. They contacted a doctor to help manage the pain.

Still, the patient’s wrist wasn’t splinted for another two days. The hospital’s rapid response team — which responds to patients during a cardiac crisis — was called to the patient’s room shortly before 5 p.m. on Nov. 24, according to the inspection report.

A doctor-in-training in orthopedics finally then addressed the fracture by placing a fiberglass splint and ace wrap.

The patient received a follow-up X-ray almost a week later and was discharged on Dec. 1, with a follow-up appointment with an orthopedic surgeon scheduled, the inspection report shows.

Staff in the behavioral health unit had not followed the hospital’s protocol for requesting a surgical consult, hospital administrators found during their incident review.

Staff were retrained on what to do when an emergency case needs to be escalated to more advanced care and how to seek a specialist consultation quickly. The training also included a refresher on best practices for keeping each other informed of new developments in patient cases, with an emphasis on hand-offs when patients are sent to a different hospital unit or workers change shifts.

Hospital administrators were already planning a meeting for key hospital workers to discuss diagnostic overshadowing. This was because of the prior incident at HUP-Cedar, in which a patient died on Nov. 4.

In that case, staff didn’t know how to respond when a patient slumped over in their walker and fell to the floor, and left the patient alone to seek help. When state inspectors investigated what went wrong, administrators noted that diagnostic overshadowing could have contributed to why nurses and techs did not insist on checking the patient’s vital signs when they initially refused.

“Caring for patients who have both psychiatric conditions and medical issues poses unique challenges,” Cunningham, the hospital’s CEO, said in an emailed statement.

For instance, it can be “difficult to distinguish between psychiatric and medical conditions when mental health-related behaviors mimic complicated medical conditions,” she said. “In all cases, however, we are committed to ensuring that the unique needs of each of our patients are addressed by our staff.”

» READ MORE: Nurses left patient to die at Penn Medicine hospital. State inspectors issued a severe warning.

Hospital administrators said they plan to train nursing staff in the behavioral health unit on diagnostic overshadowing and how completing prompt, thorough physical exams can help determine if a patient is in need of care for a physical ailment.

The hospital expects to complete all training by Feb. 2.