One year of inspections at Thomas Jefferson University Hospital: November 2024 - October 2025
Inspectors visited nearly three dozen times to investigate potential safety problems.
Thomas Jefferson University Hospital was cited by the Pennsylvania Department of Health in the last year for failing to keep a patient from setting fire in their hospital bed, turning away a person who came to the emergency department, and neglecting to monitor a patient’s vital signs.
The incidents were among nearly three dozen times health department inspectors visited Jefferson Health’s flagship hospital in Center City to investigate potential safety violations between November 2024 and October 2025.
Here’s a look at the publicly available details:
Dec. 3, 2024: Inspectors visited for a monitoring survey and found the hospital was in compliance.
Dec. 3: Inspectors followed up on a citation from August 2024 and found the hospital was in compliance. The hospital had been cited for failing to properly document details from cardiac monitoring for a patient with septic shock.
Jan. 24, 2025: The hospital was cited with immediate jeopardy, one of the state’s most serious warnings and a sign of potentially life-threatening safety problems, after a patient suffered first- and second-degree burns in their room. Inspectors found that the patient had attempted to light a cigarette while receiving treatment that involved supplemental oxygen, which can cause materials near it to catch fire. Inspectors found that Jefferson staff had failed to check the patient for smoking paraphernalia and educate them about no-smoking rules, as required by hospital protocol. The hospital posted more “No Smoking” signs, retrained staff, and updated its policies requiring smoking screening for all patients.
Jan. 30: 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.
Feb. 3: Inspectors came to investigate a complaint but found the hospital was in compliance.
Feb. 6: Inspectors came to investigate a complaint but found the hospital was in compliance.
Feb. 11: Inspectors came to investigate four complaints but found the hospital was in compliance.
Feb. 11: The Joint Commission, a nonprofit hospital accreditation agency, renewed the hospital’s accreditation, effective November 2024, for 36 months.
Feb. 12: Inspectors came to investigate a complaint but found the hospital was in compliance.
Feb. 14: Inspectors came to investigate two complaints but found the hospital was in compliance.
March 11: The hospital was cited for violating rules that require emergency departments to evaluate all patients who arrive seeking care. Inspectors found that a person walked into the emergency department saying they needed to use the restroom, and was asked to leave because the hospital does not have a public restroom. The patient said they were having an emergency and planned to check into the emergency department, but were still told to leave. Inspectors found that the dismissal violated Jefferson’s emergency department policies designed to comply with the federal Emergency Medical Treatment and Labor Act (EMTALA) — anti-patient dumping laws that require hospitals to evaluate and stabilize any patient who seeks emergency treatment. Administrators retrained staff on EMTALA protocol and updated their system for recording security incidents to better document when a provider is called by security to assess a patient who has a non-medical request, such as needing to use the restroom.
April 15: Inspectors followed up on the immediate jeopardy citation from January and found the hospital was in compliance.
April 29: Inspectors came to investigate a complaint but found the hospital was in compliance.
May 5: The hospital was cited for failing to follow protocol designed to prevent patient falls. In December 2024, an 80-year-old patient with impaired vision was admitted to the emergency department and given a drug known to cause patients to need to urinate more often. Inspectors found that the patient was initially evaluated to have a low risk of falling, but was not re-evaluated after being prescribed the medication that could increase how often they needed to get up to use the bathroom and their risk of falling. In response to the complaint, which was reported in December 2024 and finalized in May 2025, hospital administrators retrained staff on fall risk protocols and said they would monitor patient charts.
May 28: Inspectors came to investigate a complaint but found the hospital was in compliance.
May 30: Inspectors came to investigate a complaint but found the hospital was in compliance.
Aug. 14: Inspectors came to investigate a complaint but found the hospital was in compliance.
Aug. 19: Inspectors came to investigate a complaint but found the hospital was in compliance.
Aug. 19: The hospital was cited for failing to properly monitor a patient’s vital signs. Inspectors found that a provider had ordered continuous pulse oximeter monitoring for a patient, and instructions to report when the blood oxygen levels dropped below 90%. A staff member assigned to the patient could not find a pulse oximeter machine for the patient and told inspectors that they reported the issue to another provider, “but she never got back to me.” Hospital administrators acquired more pulse oximeters, retrained staff on medical supplies protocol, and said they would monitor patient hand-offs between nursing shifts.
Oct. 3: Inspectors came to investigate a complaint but found the hospital was in compliance.