An independent monitor overseeing Saint Francis Hospital found a patient died in January, the third patient death related to inadequate staffing in the hospital in the past year, according to numerous reports.
The independent monitor reports obtained through a Freedom of Information request highlight continued problems at the hospital including delays in administering medications and medication errors that point to the hospital’s continued struggle to keep staffing in line with its plan as required by the state’s hospital staffing law.
“Staffing was inadequate to meet the needs of patient care, treatment and/or services as evidenced by the lack of response to a patient’s deteriorating condition,” said the independent monitor report issued on Jan. 18. “At the time of the demise of the patient, the RN taking care of the patient had a five-patient assignment when the staffing plan stated that RNs had four-patient assignments.”
The report said further, “although the hospital had a robust rapid response program, it was not initiated in response to a patient’s deteriorating condition.”
The patient in question was reported to have seizure activity, confusion and not responsive to verbal stimuli on Jan. 29 at 1:30 a.m., according to the report.
“A rapid response was not called,” and the patient died six hours later, the report said.
The findings follow more than 100 pages of inspections from DPH over the last year that were also reviewed by the Hartford Courant highlighting alleged violations of health regulations, including instances in which staff failed to follow physician orders of continuous monitoring of patients’ cardiac rhythm and nursing staff administering oxygen without a physician.
Nurses at the hospital have reported staffing issues and high turnover rates while saying medication errors, triple assignments in the ICU and delays in patient care occurred.
With new leadership recently instituted at the hospital, Sen Saud Anwar, co-chair of the state’s Public Health Committee, and Sen. Jeff Gordon, a Woodstock Republican, who are both physicians, said they are optimistic that the changes will result in investment in personnel and address safety concerns at the hospital. But Gordon is also calling for more transparency and leadership from the state’s Department of Public Health.
DPH did not respond to questions as to whether it had a plan of correction in place regarding the patient death at Saint Francis and whether the hospital is in compliance with its state-mandated nurse staffing plan, which specifies minimum nurse to patient ratios and assistant staff to patient ratios. The agency also did not provide any comments concerning the findings of the independent monitor report.
Brittany Schaefer, public information officer for DPH, previously said “once a plan of correction is received and accepted by DPH they are uploaded and published to the elicense page, which includes such reports from the agency. To date, there are no such reports on the agency’s website for the January incident.
A Trinity Health of New England spokesperson said “nursing leadership is actively ensuring staffing plan compliance through multiple approaches, including onboarding travel RNs to supplement core staffing, utilizing effective and balanced scheduling practices and hiring additional support staff.”
The spokesperson said further to “support care at the bedside, we are strengthening direct-care staffing, including the addition of a significant number of agency RNs to support our employed colleagues.
“We recognize this is a temporary solution and we are continuing to actively recruit graduate and experienced nurses, including through the International Nurse Program,” the spokesperson said. “We are also focused on recruitment and retention efforts.”
Asked previously if DPH was investigating the patient’s death this past January, DPH declined to comment, saying they could not disclose if an investigation was taking place.
“I think it’s unacceptable what has gone on at Saint Francis for many different reasons and I think it’s repeated failure of leadership at that time,” Gordon said.
Gordon said Trinity Health of New England has made a “serious commitment to realigning leadership.
“That’s a big move,” he said. “So I’m hopeful that they will (improve) but it’s incumbent on DPH and the legislature to be watching this, to make certain that things are going in the right direction. We need to have a more open and transparent process from DPH.”
At the end of last month in response to mounting issues at the hospital, Trinity Health of New England, which owns Saint Francis Hospital, instituted new leadership with Dr. Robert Roose, who leads Trinity Health Of New England’s Community Hospitals, serving as interim president of Saint Francis Hospital and Mount Sinai Rehabilitation Hospital. Dr. Steven Hanks was designated as CEO and president of Trinity Health of New England and Trinity Health of New York.
Anwar said both Roose and Hanks are focused on “the safety of our patients and the quality of care.”
Anwar said improving staffing ratios in the hospital would address many of the issues highlighted in the independent monitor reports.
“If you have enough personnel that are taking care of patients and the ratios are safer, we will see many of these issues to be less likely,” he said.
The Trinity Health of New England spokesperson said, “we are taking decisive steps to strengthen safety, quality and the patient and colleague experience at Saint Francis and across Trinity Health Of New England.
“A new, physician-led executive leadership team is being formed, bringing established track records in delivering safety and operational excellence, ” the spokesperson said. “We have made new, targeted investments to support this work, including engaging external independent specialists to assess our current state and provide a clear roadmap to advance a high-reliability organizational culture.”
State Sen. Saud Anwar meets recently with new leadership at Trinity Health of New England and Saint Francis Hospital including Dr. Steven Hanks and Dr. Robert Roose. (courtesy of Sen. Anwar)
Trinity Health of New England also said it is “investing in new equipment across multiple clinical and non-clinical areas with recent approvals including medical equipment and infrastructure repairs.”
The health care company said it has invested more “than $1 billion over the past decade in operations and capital improvements across our region.”
Nursing staffing shortages
Nursing staff shortages are not unique to Saint Francis but are occurring across the state and country.
“Patient safety also depends on ensuring healthcare workers are supported and hospitals have the flexibility to respond to patient needs in real time,” said Paul Kidwell, senior vice president of policy at the Connecticut Hospital Association. “Like hospitals nationwide, Connecticut hospitals continue to face workforce shortages and evolving care demands, making it essential that staffing approaches remain responsive during changing conditions, including surges and emergencies.”
At Saint Francis, independent monitor reports illustrate over the last year the impact the shortages have left on the hospital.
On Feb. 12 at 3 a.m. “The ED had 94 patients including 58 inpatient boarders and 14 nurses, requiring each nurse to care for 6.7 patients.
“The nursing staffing plan allows for each nurse in the ED to care for 4.5 patients,” the report said. “At 5:35 on 2/13/26 an adverse event occurred.”
A report from AFT Nurses and Health professionals found that “unsafe patient levels for healthcare workers have been linked to poorer patient outcomes, including higher likelihood of death.
“Each additional patient added to the average nurse’s workload on a med-surg unit increased each patient’s chance of 30-day mortality by 16 percent,” the report said.
On Feb. 24 the independent monitor said that “RN staffing remains challenging.”
“Month to date ED compliance is 61%,” the report said.
While stating that nursing assistant staffing has improved, an independent monitor report from Feb 22 to March 23 found that “there continue to be shifts and units where the staffing levels do not align with the staffing plan.”
Last month, 40 radiologists from Advanced Imaging Specialists left Saint Francis after the group sued the hospital for mismanagement and lack of equipment. Last year, 15 hospitalists left Trinity Health of New England, the majority from Saint Francis, after the health system required them to shift their employment to California-based Vituity within 90 days or risk losing their jobs. An unknown number of nurses have also left the hospital.
The Hospital Staffing Law, signed by Gov. Ned Lamont in 2023, requires hospitals to be in compliance with their staffing plan 80% of the time, according to the law.
John Brady, vice president of AFT CT, said that staffing shortages create a “vicious cycle.
“It leads to staff burnout which leads to more short staffing,” he said. “It affects patient outcomes.” He said of the RNs that are registered, only half of them are working at the bedside.
Pavani Rangachari, a professor of health care administration and public health at the University of New Haven, said retention of nurses in the industry is a big problem.
“The key is responsible leadership that cares, that shows that they believe this is a strategic investment,” she said. “This is a human resource that they’re investing in. Hospitals need to see nurses not simply as a cost center but as central to the mission and the culture and long-term sustainability of healthcare.”