For more than two years, a Connecticut hospital was not “in substantial compliance” with state and federal regulations, according to the two latest Connecticut Department of Public Health inspection reports. The new reports on Saint Francis Hospital in Hartford highlight a record of continued patient safety and staffing issues, including three patient deaths.
“During the period of 8/25/2023 through 3/27/2026, the hospital was not in substantial compliance with the Conditions of Participation under Nursing Services, Patient Rights, Physical Environment, Infection Prevention Control Abx Stewardship (Antibiotic Stewardship), Surgical Services, Pharmaceutical Services, Food & Dietetic Services, and Emergency Services,” the DPH report found.
Since August 2023, the hospital was identified for immediate jeopardy nine times, 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 latest 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.
The Hartford Courant also obtained, through a Freedom of Information Request, independent monitor reports over the last year that also cited concerns about patient safety and another patient death at the beginning of this year. The state Department of Public Health’s contract with an independent monitor to provide additional oversight to the hospital was extended another six months at the beginning of this year.
Recently, Trinity Health of New England, which operates Saint Francis Hospital, named Dr. Robert Roose, who leads Trinity Health Of New England’s Community Hospitals, interim president of Saint Francis Hospital and Mount Sinai Rehabilitation Hospital. Dr. Steven Hanks was designated CEO and president of Trinity Health of New England and Trinity Health of New York.
Sen Saud Anwar, co-chair of the state’s Public Health Committee, and Sen. Jeff Gordon, a Woodstock Republican, both physicians, have said they are optimistic that the hospital will invest in personnel and address safety concerns following the leadership change. Still, the two doctors say that DPH needs to provide strong oversight over the hospital.
Oversight
The Courant sent questions to the Department of Public Health asking whether the hospital had put in a plan of correction concerning the immediate jeopardy findings the health agency issued; whether staffing improved at the hospital; and what the hospital is doing to address the issues cited in the latest DPH report.
Brittany Schaefer, public information officer for the Connecticut Department of Public Health, said in an email Friday that “our Facility Licensing and Investigations Section and our Chief told me the inquiry requires a bit of research, so she is hoping to get responses to you by early next week.”
A Trinity Health of New England spokesperson said in a statement that “with a new, experienced physician-led leadership team in place, Saint Francis is moving forward with a clear focus on strengthening operations and providing safe, high-quality care for our patients.
“Saint Francis is not in Immediate Jeopardy and the Connecticut Department of Public Health (DPH) has accepted our plans of correction,” the hospital spokesperson said. “We are deeply committed to meeting regulatory requirements and continuously improving the quality and safety of care we provide.”
The spokesperson said further that “like all hospitals in Connecticut, Saint Francis maintains a staffing committee that includes frontline nurses and nurse leaders who develop staffing plans for inpatient nursing units and the Emergency Department, as required by state law.
“These plans are submitted to DPH bi-annually,” the spokesperson said. “We also continue to recruit and hire nurses to support our staffing plans and provide the high standard of care our patients expect and deserve.”
Trinity Health of New England did not answer specifically the Courant’s questions on how it is addressing patient safety concerns raised in the DPH report and how specifically it has addressed the issue of staffing.
State Sen. Saud Anwar, co-chair of the state’s Public Health Committee, said, “I take findings like these very seriously because behind every report is a patient who placed their trust in our healthcare system and a family expecting their loved one to be safe.
“The issues identified are concerning and underscore the need for strong leadership, a culture where healthcare professionals can speak up without fear, and quality systems that prevent problems before they reach patients,” he said. “At the same time, I appreciate that the hospital has acknowledged these concerns and put forward a comprehensive plan to improve. My hope is that these actions lead to lasting change and not simply to satisfy regulatory requirements, but to strengthen patient safety, rebuild trust, and ensure that every person who walks into the hospital receives the high-quality care they deserve.”
Of the DPH reports completed in April and May, Gordon said it is integral to know “what is the follow up on these very serious findings.
“And what exactly are all of the concrete steps that Trinity Health of New England has put into place and is putting into place so we know a timeline of their actions, but also a timeline of ongoing DPH oversight and reporting,” he said. “I think we should find out the degree of oversight that DPH is doing and if there’s anything lacking or not being done in a timely manner we need to hold DPH accountable.”
Immediate jeopardy designations at the hospital
In August 2023, immediate jeopardy was identified for “failure to ensure a patient who required continuous telemetry to monitor cardiac function was assessed every two hours” and “failed to ensure the patient’s cardiac rhythm was continuously monitored.
“As a result, the patient’s change in condition was not identified in a timely manner when the patient was found pulseless and expired,” the report said.
Another immediate jeopardy was identified nearly a year later on July 22, 2024, “for failure to ensure a patient was protected from abuse when two staff members were observed by other staff members to physically throw the patient on the bed and place the patient in a therapeutic hold.
“The patient was then slapped in the face and dragged to the seclusion room,” the DPH report said.
Immediate jeopardy was identified on Jan. 9, 2025, for “failure to ensure the patient’s cardiac rhythm was continuously monitored as ordered by the physician when cardiac activity was not observed on the monitor.”
Then, on Sept. 30, 2025, immediate jeopardy was also identified for “failure to respond to a patient’s asystole (the complete absence of electrical activity in the heart) while being observed on a continuous cardiac monitor,” among other issues, the report said.
On June 13, 2025, the hospital was given the IJ designation after a “patient received 2500 micrograms of Fentanyl over a 15-minute time period in error,” resulting in the patient “experiencing a cardiac arrest,” the DPH report said.
The same designation was identified on Feb. 11 of this year when the “hospital failed to ensure a physician assessed a patient when the RN repeatedly communicated the patient’s change in condition to the physician.” The report said the patient died. The date of the patient’s death was noted on Feb. 3.
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.
Eight days later on Feb. 19, another IJ was found for failure to “administer Levophed (a potent vasopressor used to rapidly increase blood pressures in patients with acute hypotension) in accordance with the physician’s order.
“The patient went into cardiac arrest 23 minutes later and required cardiopulmonary resuscitation (CPR),” the report said.
And then a little over a month later, the hospital was once again identified for IJ after a “patient’s cardiac rhythm was not monitored for 72 minutes (intermittently), was found pulseless and not resuscitated in accordance with a do not resuscitate order.”
Staffing concerns
The DPH report said further that “based on a review of clinical records, hospital documentation and staff interviews the hospital failed to ensure staffing was adequate in the emergency department and in accordance with the hospital staffing plan to provide appropriate level of care to the patients.”
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. DPH may review violations that are filed and can assess fines of $3,500 for the first violation and $5,000 for each subsequent violation.
While the hospital was fined on Jan. 30, 2025, and Nov. 15, 2024, for not complying with the staffing law, there is no record that it was fined this year.