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Nine months of hospital inspections Hospital of the University of Pennsylvania: January to September

HUP's Cedar Avenue campus was cited for multiple violations in the first nine months of the year.

Hospital of the University of Pennsylvania is the flagship hospital of Penn Medicine.
Hospital of the University of Pennsylvania is the flagship hospital of Penn Medicine.Read moreAnton Klusener/ Staff illustration/ Getty Images

The Hospital of the University of Pennsylvania was cited by the Pennsylvania Department of Health for issues including unsanitary conditions and inadequate standards for use of urinary catheters at its Cedar Avenue facility, which specializes in mental and behavioral health services.

The citations were among 13 times health inspectors visited the hospital’s main campus and Cedar Avenue outpost to investigate potential safety problems between February and October.

Here’s a look at the publicly available details:

  1. Jan. 16: Inspectors cited the hospital for failing to properly oversee a nurse-in-training who treated a patient with a urinary catheter that was larger than necessary at the Cedar Avenue campus in September 2023. Hospital policy requires staff to use the “smallest viable” catheter size to reduce the risk of damage to the urethral lining and minimize discomfort. Inspectors found that the too-large catheter did not work properly and the patient complained of pain. Administrators met internally to discuss the incident prior to the health department’s investigation, reviewed staffing levels, and retrained staff on catheter care protocol.

  2. Feb. 6: Inspectors came to investigate a complaint but found the hospital was in compliance. Complaint details are not made public when inspectors determine it was unfounded.

  3. Feb. 20: Inspectors came to investigate a complaint but found the hospital was in compliance.

  4. Feb. 24: Inspectors came to investigate a complaint but found the hospital was in compliance.

  5. Feb. 24: Inspectors followed up on two November 2023 citations at the hospital’s Cedar Avenue campus and found the facility was in compliance. HUP - Cedar Ave was cited for failing to provide prompt emergency care after a patient was left to die on the floor while staff scrambled to figure out what to do. Later the same month, the facility was cited after a patient waited four days for staff to split and treat a broken wrist.

  6. Mar. 5: Inspectors visited for a mental health monitoring survey at the hospital’s Cedar Avenue campus and found the hospital was in compliance.

  7. Apr. 23: Inspectors came to investigate a complaint but found the hospital was in compliance.

  8. May 15: Inspectors came to investigate a complaint but found the hospital was in compliance.

  9. Jun. 11: Inspectors cited the hospital’s Cedar Avenue location for sanitation problems, including a cracked floor in a clean storage area, discolored and leaking ceiling pipes and hand sanitizer that expired in 2022. Inspectors also found catheters and other sterile equipment that had expired earlier in 2024. The hospital repaired the floor and pipes, cleaned up debris, and discarded expired supplies. Staff were retrained on maintenance protocol and administrators agreed to monitor cleaning logs for compliance.

  10. Jul. 11: Inspectors came to investigate a complaint but found the hospital was in compliance.

  11. Jul. 17: Inspectors came to investigate a complaint but found the hospital was in compliance.

  12. Aug. 15: Inspectors came to investigate a complaint but found the hospital was in compliance.

  13. Aug. 26: Inspectors visited for a special monitoring survey and found the hospital was in compliance.

  14. Sept. 25: Inspectors came to investigate a complaint but found the hospital was in compliance.