Report Reveals 2 Deaths, Medication Errors, Staffing Crises at CT Hospital

Overview of Staffing and Patient Care Issues at Saint Francis Hospital

Recent reports from an independent monitor overseeing Saint Francis Hospital have revealed significant concerns regarding patient care, including two patient deaths. These issues are closely tied to inadequate staffing levels at the hospital. The findings were obtained through a Freedom of Information request and cover over 150 pages of documentation spanning a year.

The Hospital Staffing Law, signed by Governor Ned Lamont in 2023, mandates that hospitals maintain minimum nurse-to-patient and assistant staff-to-patient ratios. According to the law, hospitals must comply with these staffing plans at least 80% of the time. The Department of Public Health (DPH) has the authority to review violations and impose fines of $3,500 for the first violation and $5,000 for subsequent ones.

State Senator Saud Anwar, co-chair of the Public Health Committee, emphasized the importance of implementing the law effectively. He stated, “If any hospital is not following the law there should be penalties as has been written in the law.” Anwar also called for DPH to pay close attention to the data provided by the independent monitor and ensure transparency.

State Representative Cristin McCarthy Vahey, another co-chair of the Public Health Committee, highlighted that the law was introduced after learning about the challenges nurses faced concerning staffing shortages. She urged the hospital to work closely with the independent monitor to provide transparency and ensure public confidence in the quality of care.

Questions on Staffing Plans and Compliance

The DPH did not respond to questions from the Hartford Courant regarding whether it was enforcing the hospital staffing law by fining Saint Francis Hospital for incidents where the independent monitor found non-compliance with staffing levels. Additionally, it did not clarify whether it verifies hospital staffing independently or relies solely on hospital reports.

According to the independent monitor’s reports from June 20 to August 18, the hospital showed improvements in critical care units but continued to face staffing issues in other areas. The reports noted that some managers and supervisors were unfamiliar with the staffing levels required by the plan. One individual claimed all units were adequately staffed, but when questioned, they were unaware of the appropriate staffing levels.

Brittany Schaefer, a spokesperson for the DPH, mentioned that Saint Francis’ last submission regarding its staffing plan was in July 2025, and the hospital reported compliance with the requirement to have a nurse staffing plan and being in compliance with at least 80% of the nurse staffing.

Julia Williams, regional director of marketing and communications for Trinity Health of New England, which owns Saint Francis Hospital, stated that the hospital produces semi-annual nurse staffing plans for the DPH and collaborates with an independent expert compliance consultant.

Trinity Health did not answer questions about staffing shortages or whether the hospital met the 80% compliance requirement. It also did not address the hospital’s staffing levels.

Ongoing Oversight and Concerns

In August, the State Department of Public Health decided to continue oversight of Saint Francis Hospital with an independent monitor in place after inspections uncovered serious violations of patient safety regulations. Over 100 pages of inspection reports reviewed by the Hartford Courant highlighted alleged violations, such as failure to follow physician orders for continuous monitoring, administering oxygen without a physician, and not ensuring isolation precautions.

Nurses who spoke anonymously expressed concerns about staffing levels and their impact on patient care. They mentioned that many nurses had resigned, leaving the hospital short-staffed and not adhering to the staffing plan. A former nurse described situations where one nursing assistant was responsible for 16 patients, causing challenges in providing adequate care.

In April, approximately 30% of hospitalists left Trinity Health of New England, which operates Saint Francis Hospital and several other facilities. Many physicians left due to a requirement to shift employment to California-based Vituity within 90 days or risk losing their jobs.

Staffing Shortages and Patient Care Issues

Numerous reports from the independent monitor highlight staffing shortages. During the period from March 24 to April 17, the department did not meet its defined staffing levels for 22 four-hour shifts and 27 eight-hour shifts. In the Emergency Department, staffing levels were not met for 11 four-hour shifts during the same timeframe.

The independent monitor also cited instances where staffing levels did not match the staffing plan. While the ICU met its target, other departments continued to face shortages. High patient-to-nurse ratios were noted, with nurses caring for six patients each until the next shift.

In July, the monitor reported that ambulation of patients was limited due to staffing, and nurses had no breaks. Charge nurses were conducting interviews while caring for multiple patients. ED staffing data were often unavailable for review.

Patient Deaths and Care Failures

The independent monitor reports cite two patient deaths linked to medication errors and poor patient care. On April 27, a patient in the Emergency Department did not receive a nursing assessment for over 24 hours. When the nurse finally entered the room, the patient was covered in emesis and appeared to have aspirated. The patient was intubated and later placed on comfort measures only before passing away.

Another patient died on January 31 after experiencing a sustained rhythm change without notification to the nurse or provider. Vital signs were not documented for over 10 hours, and no nursing assessments or safety rounds were conducted during this time.

In May, a patient admitted for sepsis due to a venous ulcer did not receive a full wound assessment until a week later. By then, deep tissue injuries had developed. A CT scan ordered at 4 a.m. was not completed until 9 p.m., leading to the patient's deterioration and transfer to intermediate care.

The hospital also failed to report a sentinel event involving a retained foreign object in a patient’s femur. On July 21, a ventilator order was delayed, worsening the patient’s acidosis.

Medication errors, such as delayed insulin administration, were also noted in the reports.