Two Connecticut hospitals owned by the same health system have accumulated more of the federal government's most serious patient safety findings than any other hospitals in the state.
Saint Francis Hospital in Hartford has been issued nine immediate jeopardy citations since January 2023, the most of any hospital in Connecticut. Johnson Memorial Hospital in Stafford ranks second with five over the same period, according to the state Department of Public Health. Both are operated by Trinity Health of New England, part of one of the largest nonprofit Catholic health systems in the country.
The finding comes from reporting by CT Mirror, which reviewed Centers for Medicare and Medicaid Services reports going back to 2020.
A Citation That Is Often Misunderstood
An immediate jeopardy finding is not a malpractice verdict, a lawsuit, a fine, or a determination that a specific patient was harmed. Readers frequently conflate these, and the distinction changes what the number means.
It is the most serious quality and safety finding CMS can issue to a hospital. The agency defines it as a situation in which a provider has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death.
The findings come from surveys, typically conducted by state health department inspectors acting on behalf of CMS, often triggered by a complaint. A citation reflects what surveyors documented at the time of the survey. Hospitals must submit a plan of correction, and the finding can be lifted once the immediate risk is addressed.
The word immediate is doing real work. The standard concerns risk, which means a citation can be issued where serious harm was possible without anyone being injured. It can also follow a case where someone died.
The documented examples are specific. In one April 2023 case at Johnson Memorial, a patient admitted to the emergency department with suicidal ideation was not provided a timely suicide risk assessment, according to a CMS report published that month.
Comparing Hospitals Requires Caution
Raw citation counts across hospitals of different sizes and types are a genuinely imperfect measure, and any responsible reading has to account for that.
Saint Francis is a Level 1 trauma center with more than 600 beds. Larger hospitals treating sicker patients through emergency and trauma pathways generate more encounters, more complaints, and more surveys. A small community hospital and a major trauma center are not directly comparable on a count.
Reporting rates also vary. Citations often follow complaints, and complaint volume is influenced by patient population, staff willingness to report, and local media attention as much as by underlying safety performance.
Trinity Health of New England's Connecticut hospitals include St. Mary's in Waterbury, which does not appear in the same pattern, complicating a simple system-wide explanation.
The state context runs the other direction as well. Connecticut ranked first nationally in the Leapfrog Group's Hospital Safety Grades for this spring, with 64.3 percent of the state's graded hospitals earning an A. Leapfrog grades and CMS citations measure different things through different methods, and a state can lead one while individual facilities struggle on the other. In that same report, Saint Francis received a C.
Regulatory reports attributed problems at the two hospitals to staffing shortages, closed units and inadequate patient monitoring. Hospital representatives have pointed to measurable improvement at Johnson Memorial, including recent safety grade gains, while Saint Francis remains under a state consent order. Elected officials have criticized the Michigan-based parent system over resource allocation.
Staffing Sits Underneath Most of the Findings
The documented failures share a pattern that is worth naming, because it points to a cause rather than a list of incidents.
Surveyors attributed problems at both hospitals to staffing shortages, closed units, and inadequate monitoring. A delayed suicide risk assessment or a missed change in a patient's condition is usually a monitoring failure. Monitoring failures usually trace to how many staff are watching how many patients.
Reporting by Connecticut Public noted that the system also operates a rehabilitation hospital in Hartford and Mercy Medical Center in Springfield, Massachusetts.
The Practical Meaning for a Patient
A citation history is one input into a decision, not a verdict on whether someone should go to a particular hospital.
For emergency care, this rarely applies at all. In a suspected heart attack, stroke, serious injury or any situation where minutes matter, the nearest appropriate facility is the right facility, and a trauma center designation carries substantial weight. Bypassing a closer hospital to reach one with a cleaner record is a decision that can cost more than it gains.
For planned care, comparison shopping is realistic. Someone scheduling elective surgery, choosing where to deliver a baby, or selecting a hospital for a planned procedure has time to look.
Publicly available tools exist for this. CMS publishes hospital quality measures and survey findings through its Care Compare tool, and the Leapfrog grades are free to search. Neither captures everything, and reading both is more informative than reading either alone.
Questions worth asking a hospital directly include nurse-to-patient staffing ratios on the relevant unit, volume for the specific procedure being considered, and what the plan is if a patient's condition deteriorates overnight.
Patients and families can also act during a stay. Most hospitals have a rapid response mechanism that families can activate when they believe a patient is deteriorating and not being heard. Asking at admission how to escalate a concern, and who the charge nurse and patient advocate are, is reasonable and takes a minute.
Anyone who believes they experienced unsafe care can file a complaint with the Connecticut Department of Public Health, which conducts the surveys that generate these findings.
State officials have been pressing Trinity Health for improvements. MedicalDaily will report any subsequent citations, corrective action outcomes, or enforcement steps.
Key Questions Answered
What is an immediate jeopardy citation? The most serious finding CMS can issue, indicating a provider placed patients at risk of serious injury, harm, impairment, or death.
Is it the same as a malpractice finding? No. It is a regulatory survey finding about conditions at a facility, not a court judgment or a determination that a specific patient was harmed.
Which hospitals were cited most? Saint Francis Hospital in Hartford with nine since January 2023, and Johnson Memorial Hospital in Stafford with five.
Does hospital size affect the count? Yes. Larger hospitals and trauma centers generate more encounters, complaints, and surveys, so raw counts are not directly comparable.
Should someone avoid these hospitals in an emergency? No. For time-critical emergencies, the nearest appropriate facility is generally the right choice.
Where can patients check a hospital's record? CMS publishes quality measures and survey findings, and the Leapfrog Group publishes free safety grades.
How does someone report unsafe care? By filing a complaint with the Connecticut Department of Public Health, which conducts the surveys behind these findings.
