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

The patient slumped over a walker, then slid down the wall and collapsed, while two nurses and two technicians at a Penn Medicine hospital stood over the motionless patient. Unsure what to do, the staff walked away to figure out how to handle the situation.

The nurses and techs at the Hospital of the University of Pennsylvania-Cedar Avenue left the fatally ill patient alone and didn’t start CPR for 10 minutes. By then, it was too late.

The patient died while lying on the floor of the hospital’s Behavioral Health Unit, state health inspectors said in a report released last week.

The state’s report noted that hospital leaders — who also investigated the incident internally — had concerns about “diagnostic overshadowing,” in which staff might wrongly assume that a patient admitted with behavioral health issues wouldn’t then develop a life-threatening medical crisis.

The November incident prompted the state to issue its most serious safety warning at HUP-Cedar, an outpost of Penn’s flagship hospital since 2021. Penn now provides emergency mental health and general emergency department services, psychiatric and addiction care at the former Mercy Philadelphia Hospital site at South 54th Street and Cedar Avenue in West Philadelphia. The hospital has 31 inpatient psychiatric beds and 16 beds for detoxification.

Health inspectors had placed HUP-Cedar in “immediate jeopardy,” signaling life-threatening concerns. They lifted the sanction within hours after confirming that the hospital had immediately educated behavioral health staff on what to do when a patient falls and how to call a code blue, a term commonly used to summon emergency aid for a patient experiencing a medical emergency.

The hospital remains under state scrutiny, however, and has until Jan. 25 to address its failures to ensure patient safety and provide prompt care for a patient in medical distress.

In the state’s report, inspectors concluded that the patient’s death “could have possibly” been prevented if staff had acted more quickly.

When nurses realized the patient was in respiratory distress, staff didn’t know how to call a code blue and “left the patient to get a computer,” the report says. Inspectors also found that the hospital had no specific policy requiring staff to immediately check vital signs, such as pulse and blood pressure, when patients fall or staff see them lie down on the floor.

The state report notes that “diagnostic overshadowing” — a phenomenon where bias causes medical providers to wrongly presume that a patient’s behavior or physical symptoms stem from his or her mental illness — may have factored into the staff’s failure to recognize an emergency.

» READ MORE: How a doctor’s bias can put patients at risk

Hospital leaders proposed an improvement plan, which is detailed in the 58-page state inspection report.

A key component includes educating all staff about the danger of diagnostic overshadowing. Hospital leaders had identified it as a potential challenge for Behavioral Health Unit staff during a Nov. 27 meeting.

”We are saddened by the loss of this patient and are fully cooperating with the Pennsylvania Department of Health in connection with this matter,” a Penn Medicine spokesperson said, adding: “Patient safety is an essential cornerstone of care” at all Penn facilities and the hospital’s “plan of correction demonstrates how seriously we take this commitment.”

State inspectors showed up at the hospital unannounced after receiving a complaint about the incident and began a two-day, on-site investigation.

The report does not say who filed the complaint, but Pennsylvania law required HUP-Cedar leaders to alert the state of serious safety lapses. The state report does not disclose details about the patient, including gender, age, and reason for hospital admission.

Inspectors arrived on Nov. 14 — 11 days after the patient died on the second floor, where the hospital provides inpatient psychiatric treatment and drug and alcohol detoxification.

Around 3 p.m., inspectors issued an “immediate jeopardy” warning, which means they found safety problems that endangered patients’ lives. The hospital had to quickly correct the problems identified, or risk losing government funding and its national accreditation.

By 7:40 that night, inspectors removed the “immediate jeopardy” flag after verifying that hospital leaders had taken steps to make it clear that nurses and mental health technicians must fully check vital signs when patients fall. The revised policy also applies when a patient is thought to have lain down intentionally on the floor.

A nurse must stay with the patient the entire time. Staff also must alert the on-duty psychiatrist and start rapid-response protocols if they see concerning changes in the patient’s physical or mental status.

Hospital leaders are training staff to consider all possible medical causes for any change in a patient’s behavior, “which could potentially mimic psychiatric illness, including, but not limited to, suspected intentional falls,” according to the state report.

Inspectors reviewed the patient’s medical record, interviewed staff, and reviewed video footage to determine what unfolded for their report:

At about 8:45 p.m. on Nov. 3, the patient stepped slowly down the hallway with a walker, then stopped to lean against a wall and slumped over the walker. Staff approached and tried to take the patient’s vital signs. The video, which had no audio, showed staff saying something to the patient and then walking away without checking vital signs.

Two mental health technicians arrived. One tapped on the walker, as the patient remained bent over it. The patient became physically unstable. Techs steadied the patient. They stood talking and looking at the patient, then walked away toward the nurses’ station.

Two nurses walked up to the patient, who was still drooped over the walker and using the wall for support, then left. The patient collapsed. “The patient is lying on the floor at door to unit, not moving. No staff is with patient,” the state report says.

The nurses returned with a mobile workstation. They crouched down and looked at the patient. One nurse straightened out the patient. Both nurses then left, walking toward the nurses’ station, while the patient remained “unmoving on [the] floor.”

By then, the two techs had returned and stayed with the patient. They stood looking down at the patient with their cell phone flashlights on.

The nurses came back. One had a crash cart, a wheeled unit with lifesaving equipment. The other nurse had a vital sign machine and applied a blood pressure cuff. Moments later, two different nurses arrived: a nurse supervisor and a “rapid response nurse,” an expert in critical care.

The nurse supervisor noticed the patient “was gray in color” and “asked if anyone checked for responsiveness and no one answered,” the report notes. The supervisor checked the patient and felt no pulse.

The patient’s primary nurse later told state inspectors that “they were unsure on how to call a code and left the patient to get a computer,” according to the report.

The nurse supervisor called a code blue at about 8:55 p.m. The rapid response nurse started chest compressions.

An emergency department provider arrived, and resuscitation efforts stopped at 9:26 p.m. The patient was transferred to the morgue just before 10 p.m.