DPH finds serious violations of patient safety at CT hospital

Oversight of Saint Francis Hospital will continue for another six months after inspections uncovered “serious violations of patient safety regulations and protocols at the hospital” this past summer, according to the state Department of Public Health.

Brittany Schaefer, spokesperson for DPH, said Saint Francis entered into a consent order with DPH in September 2024 because of “the hospital’s failure to meet minimum staffing requirements, which are in place to protect the health and safety of the patients served by the hospital.”

More than 100 pages of inspections from DPH over the last year that were reviewed by The Hartford Courant highlight violations of health regulations including failing to follow physician orders that directed continuous monitoring of patients’ cardiac rhythm; nursing staff administering oxygen without a physician; incidents of patients not receiving medications as directed by a doctor; failing to ensure isolation precautions with patients with illnesses that required such protocols; among others.

An inspection report this past June stated that the hospital was identified for immediate jeopardy on June 13, which “represents a situation in which noncompliance by providers, suppliers or laboratories has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death,” according to the Centers for Medicare & Medicaid services.

The designation was in reference to an incident that occurred on June 3, when, the report states, the “hospital failed to ensure staff followed the standard practice for medication administration” with a patient receiving “2500 micrograms of Fentanyl over a 15-minute time period in error” resulting in the patient going into cardiac arrest.

The immediate jeopardy designation was lifted five days later after the state agency verified that the hospital implemented immediate corrective actions, the report stated.

Stephanie Valickis, regional communications manager for Trinity Health of New England, said in an email that Trinity was working “in close partnership with the Connecticut Department of Public Health to ensure the highest standards of care and accountability.

“Patient safety is not just a priority – it is a core value that guides every encounter,”  she said. “We underscore that commitment by welcoming opportunities for improvement and thereby ensuring our status as a high reliability organization with a strong culture of safety and quality as demonstrated by our 13th consecutive recognition as a Best Regional Hospital by U.S. News & World Report.”

State Rep. Cristin McCarthy Vahey, co-chair of the Public Health Committee, said she is glad that DPH is taking the necessary steps “to assure the patients at Saint Francis are safe.

“I hope and expect Saint Francis to continue to take necessary measures to rectify the situation,” she said. “I am glad that they are cooperating but I hope this can be resolved as quickly as possible.”

State Sen. Saud Anwar, co-chair of the state’s Public Health Committee expressed concerns about the reports, saying their content reaffirms the concerns that patients and some of the health care workers have raised about staff shortages and patient care.

He explained the importance of DPH’s oversight of hospitals in instances where patient safety concerns are raised.

“Patient safety is of paramount importance,” he said. “There are systems in place to make sure that the hospital comply with the expectations and keep that priority. … When a hospital is unable to address this it is important for the DPH and the state to intervene and help them set the priorities and resources in a manner where patients’ wellbeing will remain the most important part of the health care delivery.”

Staff shortages

In April, an estimated 30% of hospitalists left Trinity Health of New England, which operates Saint Francis Hospital, Saint Mary’s Hospital in Waterbury, Johnson Memorial Hospital in Stafford Springs and Mount Sinai Rehabilitation Center in Hartford.

Those physicians, with the majority of the 15 from Saint Francis Hospital, decided to part ways with Trinity after the health system required them to shift their employment to California-based Vituity within 90 days or risk losing their jobs. Several previous physicians at Saint Francis expressed concerns to the Hartford Courant this past winter about patient safety, explaining that the hospital was already suffering from a staff shortage.

Dr. Damian Kalisiewicz, who previously worked at Saint Francis Hospital primarily part-time because of what he described as a grueling workload due to a yearslong staffing shortage, told the Hartford Courant this past winter that physicians should be seeing 18 patients in a 12-hour period but instead were seeing 22 to 24 patients. He emphasized that burnout and quality of care starts to deteriorate over 18 patients.

He said at the time he was seeing patients waiting in the ER at times for days for a bed and not obtaining MRIs in a reasonable amount of time. During the winter the hospital was short a minimum of at least seven full-time physicians for the hospital medicine department, he said.

Vituity describes itself as a 100% physician-owned democratic partnership with a network of 6,000 clinicians caring for more than 10 million patients at over 690 practice locations.

Valickis did not respond to questions from the Courant concerning whether Vituity has addressed the staff shortage, the number of staff the hospital employs and whether it has lost personnel due to the partnership with the California-based company.

DPH inspections

The DPH report highlights several examples of patient care impacted by issues at the hospital.

On Jan. 9 of this year another designation of immediate jeopardy was identified for the hospital after interviews with 11 patients revealed the “hospital failed to meet the needs of patients by following physician orders that directed continuous monitoring of the patient’s cardiac rhythm and the administration of medication as prescribed.

“The nursing service must have adequate numbers of licensed registered nurses, licensed practical nurses and other personnel to provide nursing care to all patients as needed,” the report stated.

The report cites an incident on April 2 where a patient was required to receive consistent cardiac monitoring and oxygen therapy. The patient was transferred to a receiving unit during a shift change without telemetry monitoring when a nurse noted the patient was in distress. The patient then was intubated, according to the report.

“The RN stated that, according to the physician’s orders, the patient should not have arrived at her unit without being attached to pulse oximetry and telemetry and without a nurse monitoring the patient during the transfer as this put the patient at risk of delayed recognition and intervention for any deterioration in the patient’s condition during the transport,” the report stated.

In another incident on April 10, another patient was transported to diagnostic imaging without “supplemental oxygen.”

“Subsequently, the patient experienced shortness of breath and lightheadedness and the rapid response team was called,” the report stated.

Also in January based on interviews with 10 patients, DPH inspectors learned that several patients with illness requiring isolation protocols were not isolated including a patient with COVID and another with meningitis.

Another incident noted by DPH inspectors in January included a surgical issue where “the hospital failed to ensure the correct anterior cervical disc fusion procedure was performed on the correct vertebral disc level,” according to the report.

Another DPH inspection report found that in September 2024 “the hospital failed to ensure the patient with a history of swallowing foreign objects was adequately supervised and failed to ensure the environment was safe.

“The patient swallowed a needle, a shower curtain hook, a plastic bottle cap and crayon while on 1:1 constant observation and was transferred to a higher level of care for removal,” the report stated.