State fines St. Raphael’s

By Gregory B. Hladky
Capitol Bureau Chief
HARTFORD — State health officials have fined the Hospital of St. Raphael $12,000 for patient care violations that included non-fatal medication overdoses and failures to properly monitor and treat bed sores.
The state action marks the second time since 2006 that St. Raphael’s has been penalized for improper patient care.
In addition to payment of the fine, hospital officials have voluntarily agreed to make improvements in staff procedures, training and record keeping. Unannounced state inspections that turned up the problems were conducted in early June and September 2007.
A spokeswoman for St. Raphael’s said many of the state-ordered reforms have already been put into effect and remaining improvements will be completed soon.
"We formulated a corrective action plan immediately," said Janeanne Lubin-Szafranski, vice president and general counsel for St. Raphael’s.
In a prepared statement, St. Raphael’s officials said inspections by the state Department of Public Health were part of the routine visits made annually by the many regulatory and accrediting agencies that oversee care at hospitals around Connecticut.
"Saint Raphael’s takes these reviews very seriously as they help the hospital further improve the excellent, safe care provided to thousands of patients each year," hospital officials said in the statement. "Saint Raphael’s goal is always to be in compliance with or exceed the many hundreds of standards these groups have."
In 2006, the state fined the hospital $18,000 after a 21-year-old patient died as a result of an overdose of medication. That incident also resulted in a consent order to improve hospital procedures.
Lubin-Szafranski said that, while the 2006 consent order and the 2008 agreement both involved medication procedures, the problems involved were "not similar. … It was a different issue."
William Gerrish, a spokesman for the state Health Department, said his agency has kept a "closer watch (on St. Raphael’s) than we normally would because of the 2006 violations.
"We always follow up on our consent orders," he said.
Gerrish said St. Raphael’s officials "are being cooperative and compliant with the department’s demands."
According to Gerrish, state health officials have occasionally levied fines of more than $200,000 as a result of serious patient care violations at some Connecticut hospitals. But he said smaller fines are far more frequent.
The latest fine resulted from inspections at St. Raphael’s that began last June 6, 7 and 8. Another unannounced inspection was conducted on Sept. 17.
St. Raphael’s President and Chief Executive Officer David Benfer signed the agreement with the state on Jan. 3.
The hospital has already hired an independent nursing expert to review St. Raphael’s wound care program and recommend improvements in the way staff monitors and treats bed sores and other types of pressure ulcers.
Another of the consent agreement’s requirements, to have a staff pharmacist review all doctor’s orders for regulating patient medications, was put into effect last summer.
The unannounced state inspections last year included findings that:
-Staff failed to properly administer and monitor patient medications in several instances. In one case, a patient with congestive heart failure, pneumonia and respiratory failure was given a morphine drip and received an overdose because doctors failed to provide detailed instructions to staff.
- Five different patients with bed sores and other pressure ulcers weren’t being properly monitored and treated.
- A refrigerator used to keep medications cold was malfunctioning and failed to maintain the recommended temperature.
- Infection control practices, such as nurses changing gloves or washing hands, weren’t always followed.
Gregory B. Hladky can be contacted at ghladky@nhregister.com or (860) 524-0719.