Waterbury Hospital

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 50059 Based on a review of medical records, hospital documentation, and staff interviews, for one of three patients (Patient #198), reviewed for change in condition, the hospital failed to ensure medical staff appropriately escalated care concerns regarding the patient’s continued decompensating respiratory status. The patient was reintubated (a tube placed in the trachea to assist with breathing) after nine hours of labile respiratory status. The finding includes: Patient #198 was admitted to the hospital after a motor vehicle accident with diagnoses of intracranial bleed and respiratory distress, four fractured ribs, and a fractured femur. The patient was intubated in the emergency room and transferred to the intensive care unit (ICU). Review of the patient’s record dated 9/28/2025, identified that Patient #198 was extubated (breathing tube removed) at 10:46 A.M and was placed on 6 Liters of oxygen via nasal cannula. The Nursing vital signs documentation, dated 9/28/2025, identified that at 1:45 PM-2:10 PM, the patient’s oxygen levels decreased to 81-88% (normal 94-100%), requiring an increase in oxygen delivery to a 50 % venti mask. At 6:55 PM, the patient’s oxygen saturation was 85% and the patient was placed on a 15-liter non-rebreather mask, then changed to a 15-liter OxyMizer (specialized oxygen nasal cannula). A nurse’s progress note dated 9/28/ 2025, at 10:53 PM, identified that the RN assumed care of Patient #198 at 7:00 PM. The note identified that the patient continued to remove his/her oxygen and was no longer able to maintain oxygen saturations on 6-liter oxygen via nasal cannula. The patient was placed on a non-rebreather mask at 15 liters, and the respiratory therapist was notified, the patient then changed to a 15-liter Oxymizer, and the physician was notified. The Pulmonologist plans/orders dated 9/28/2025 identified titrating oxygen to keep the patient’s oxygenation levels greater than 92%. A nurse’s note dated 9/28/2025 identified that at 11:05 PM, the patient’s oxygen saturation again decreased to 88%, and the patient was placed back on a 15-liter non-rebreather mask. The patient remained on this setting until 3:16 AM, when the patient desaturated to 66% requiring manual bag valve mask ventilation. Review of the nurse’s progress note dated 9 /29/2025, at 3:16 AM, revealed that Patient #198 desaturated to 66% and needed manual ventilation via bag valve mask. The surgical resident was called to the patient’s bedside, and a chest X-ray and arterial blood gases were obtained. The patient responded well to the bag valve ventilation was placed on high-flow nasal oxygen (60 liters) via nasal cannula, and oxygen saturations ranged from 79% to 100% throughout the remainder of the night (3:00 AM-7:00 AM). Review of the laboratory values dated 9/29/2025, at 3:29 AM identified Arterial Blood Gas results identified a PH ( Percentage hydrogen - measure blood acid/base) balance of 7.53, (normal 7,35-7.45), PCo2 ( measurement of amount of carbon dioxide in arterial blood), of 30 (normal 35-45), Po2 (measures how much oxygen is in the blood) 41(normal 80-100), Base Excess ( measures amount of base or acid needed to return a normal balance), 1.6 (normal -2-+2), HCo3 (measures amount of bicarbonate in the blood) 24 (22-26) and a hemoglobin (protein that carries oxygen from the lungs) of 7.4 (normal 14 to 18) and Hematocrit (percentage of red blood cells in the total volume of blood) of 21.4 (normal 42-50). The nurse’s progress note dated 9/29/2025, at 7:11 AM, identified that Patient #198 was confused throughout the night, tachypneic, with shallow, abdominal breathing, difficult to oxygenate, with episodes of desaturation, long periods to recover, weak, ineffective cough, and was maintained on high flow nasal cannula. At 7:35 AM, Patient #198 desaturated to the 70s, was manually ventilated, placed on a Continuous Positive Airway Pressure mask (CPAP helps with breathing by keeping the airway open) and ultimately reintubated. The medical record also identified that the patient failed CPAP and needed manual ventilation to increase saturations via the endotracheal tube. Review of the Event Note dated 9/ 29/2025, at 10:57 AM identified that Patient #198 had frequent episodes of desaturation on high flow nasal cannula and CPAP, required bag valve mask ventilation support for adequate oxygenation, and the decision was made to call anesthesia for a rapid sequence intubation. Post intubation, the patient was tachycardic and hypotensive, required manual ventilation with the endotracheal tube, vasopressors, and sedation for ventilator compliance and hemodynamic stability. Interview with Registered Nurse (RN#160) on 10 /1/2025, at 10:30 AM stated that on September 28, 2025, she cared for patient #198 from 7:00 PM to 11:00 PM. RN#160 revealed that the patient was restless and agitated, and frequently removing the nasal cannula. The RN stated she contacted the surgical resident (MD#161), and a non-rebreather (NRB) mask was ordered. She further identified that she made multiple calls to MD#161 regarding the patient’s respiratory status, and the Physician stated that the patient was to remain on the NRB. The RN stated that the patient was maintained on the NRB when she reported off to the night shift nurse. In an interview with RN#161 on 10 /1/2025, at 11:20 AM the RN stated he assumed care of patient # 198 at 11:00 PM and revealed that the patient was restless, agitated, and confused at times, pulling off the oxygen and desaturating. RN#160 stated he called the surgical resident many times, and the patient was changed to high-flow oxygen with an Oxymizer. RN#161 stated he called the MD#161 about 3:00 AM to make him aware that the patient’s oxygen level had dropped to 66% and the patient at this time needed to be manually ventilated with a bag valve mask. RN#161 stated the MD#161 arrived immediately to at the unit and wanted the patient left on high flow oxygen 60 liters, as the patient’s oxygen levels improved with manual ventilation. RN#161 stated that blood was drawn, including arterial blood gases, and that the results were reported to MD#161. RN#161 stated the patient had labile oxygen saturations for the remainder of the night shift and needed to be manually ventilated 2 more times. RN#161 stated that the day shift surgical resident (MD#164) arrived on the floor, ordered continuous positive airway pressure (CPAP); however, the patient was unable to maintain his/her oxygen levels on CPAP, leading to reintubation at 8:22 AM. RN#161 further stated that the charge nurse and the nurses on the unit were aware of the patient’s status, and revealed that he was not comfortable escalating his concerns to his supervisor or the attending, as the surgical resident was available and aware of the patient’s status. Interview with the MD#161 (Post graduate year 3) on 10 /2/2025, at 12:10 PM, identified that he was called by the nursing staff multiple times related to the patient’s decompensating oxygen levels. The MD stated that Patient #198 had been extubated for less than 24 hours, and the goal was to exhaust all interventions before considering reintubation. MD #161 stated he ordered a non-rebreather mask, high flow oxygen, nebulizer treatments, and was aware that the patient needed to be manually ventilated. He stated he was aware of the critical blood gas results and did not repeat them as he saw improvement in the patient’s oxygen level after having been manually ventilated but was not aware of the low blood count levels, as he had not reviewed the lab results, and did not recall the nurse reporting the results to him. He further stated that he signed out to the day surgical resident about 6:30 AM and was aware that the patient was reintubated a short time later. MD# 161 stated retrospectively that he should have consulted with his Attending or the Chief and possibly would have reintubated. Interview with MD #160 (Chairman of the Board for Orthopedics) on 10/1/ 2025, 3:09 PM stated that Patient #198 was medically and surgically complex. Once all interventions to prevent reintubation had been exhausted, and the patient needed to be manually ventilated, the patient, should have been reintubated. MD#160 stated that surgical residents always could reach out for guidance in managing clinically complex patients to the chief resident, the attending, or to the Chair. Interview with MD #162 (covering Attending Physician) on 10/9/2025, at 12:00 PM stated the expectation is that the surgical residents implement all possible interventions (oxygen, labs), then reach out to the senior resident, chief resident, or the attending if there are still concerns. He further stated he was the covering attending and had not been made aware of the patient’s respiratory distress during the night, and that the resident could have reached out to him. In an interview with MD #163 (Surgical Residency Medical Director) on 10/ 9/2025, at 12:15 PM the MD stated that all Residents are encouraged to update the Senior Residents, Attending, or Coordinator with changes in a patient’s condition to assist with the continuum of care. The MD revealed that he would have expected that concerns with this patient would have been escalated to the next level, which was not done. MD#163 also stated that Junior Residents (PG3) have a chief resident (PG4) who is off campus, that they can call to come to the hospital if needed, or the PG# can call the attending, or lastly the section chief. Medical staff bylaws amended 10/1019 identified that the Medical Staff accepts its role in patient safety and the quality of care provided. Review of the Policy Chain of Command for the Management of Patients dated 11/2024 directs, in part, that the chain of command is the formal line of authority, communication, and responsibility within an organization. Hospital staff is expected to utilize the chain of command to fulfill their duty to advocate for the patient when they have concerns regarding patient safety or any questions regarding patient care. Hospital staff bear significant accountability for interviewing when it appears that decisions and judgments are not consistent with the standard of care.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 47454 Based on a review of medical records, hospital documentation, sand staff interviews, for four of ten patients (Patient #192, #193, #194, and #195) who were reviewed for Intensive care nursing assessments, the hospital failed to ensure that staffing was appropriate to ensure that assessments were completed timely and in accordance with hospital policy. The findings include: Review of Intensive Care Unit (ICU) staffing identified that on 9/29/2025 at 12:00 AM the unit had a census of 21 patients requiring eleven (11) nurses, the acuity ratio required one (1) nurse for every two (2) patients. The staff schedule identified that the unit was staffed with nine (9) nurses, with two (2) nurses having a three (3) patient assignment. Review of ICU staffing on 9/29/2025 at 7:00 AM identified that the unit had a census of twenty-one (21) patients with twenty (20) patients requiring eleven (11) nurses, the unit acuity ratio required one (1) nurse to every two (2) patients and one patient requiring a nursing ratio of one (1) nurse to three (3) patients. The ICU had nine (9) nurses working during the shift. Two nurses had a three (3) patient assignment. Review of clinical records with the Director of Quality on 10/1/2025 at 1:22 PM identified the following: a. Patient # 192 was admitted to the hospital with acute encephalopathy and was intubated. Review of the head-to-toe adult intensive care unit (ICU) systems assessment dated 9/29/2025 failed to identify that a full body system nursing assessment was completed every four (4) hours. Review of nursing assessments identified that a head-to-to-toe adult ICU systems assessment was completed on 9/29/2025 at 12:00 AM and 12:00 PM (12 hours between assessments). Review of staffing identified that Registered Nurse # 166 cared for Patient #192 between the hours of 12:00 AM and 12:00 PM and was assigned three (3) patients, although the acuity ratio required one (1) nurse to two (2) patients. b. Patient # 193 admitted to the hospital status post cardiac arrest and was intubated. Review of the head-to-to-toe adult ICU systems assessment dated 9/29/25 failed to identify that a full body system assessment was completed by nursing every 4 hours. Review of nursing assessments identified that a head-to-to-toe adult ICU systems assessment was completed on 9/29/25 at 12:00 AM and 11:30 AM (11 hours and 30 minutes between assessments). Review of staffing identified that RN # 166 cared for Patient #193 between the hours of 12:00 AM and 12:00 PM and was assigned three (3) patients although the patient acuity required one (1) nurse for two (2) patients’ ratio. c. Patient # 194 was admitted to the hospital for thrombocytopenia (low levels of platelets which are required for blood clotting) on 9/28/25. Review of the head-to-toe adult ICU systems assessment failed to identify that a full body system assessment was completed by nursing every 4 hours. Review of nursing assessments identified that a head-to-to-toe adult ICU systems assessment was completed on 9/29/25 at 12:00 AM and 12:00 PM (12 hours in-between assessments), and then at 8:00 PM (8 hours since the last assessment at 12:00 PM). Review of staffing identified that RN # 166 cared for Patient # 194 between the hours of 7:00 AM and 12:00 PM and was assigned three (3) patients with an acuity ratio that required one (1) nurse to two (2) patients. d. Patient # 195 was admitted to the hospital for an aortic valve replacement on 9/24/25. Review of the head-to-toe adult ICU systems assessment failed to identify that a full body system assessment was completed by nursing every 4 hours. Review of nursing assessments identified that a head-to-to-toe adult ICU systems assessment was completed on 9/29/2025 at 4:00 AM and 12:00 PM (8 hours in-between assessments). A review of staffing identified that RN # 171 cared for Patient #195 between the hours of 7:00 AM and 7:00 PM and was assigned three (3) patients with the unit acuity ratio requiring one (1) nurse to two (2) patients. Interview with RN #171 on 10/1/2025 at 1:13 PM identified that on 9/29/2025 she was assigned as the charge nurse in the ICU and cared for three (3) patients although the acuity ratio required one (1) nurse to two (2) patients. RN # 171 identified that she cared for Patient #195 but did not get to assess the patient’s timely manner as she was focusing on titrating intravenous medications, monitoring vital signs and notifying physicians about concerns. RN #166 was unavailable for an interview. Interview with Manager # 2 on 10/1/2025 at 2:10 PM identified the expectation is that nurses complete a full head to toe assessment on all ICU level of care patients every four (4) hours. Manager # 2 identified that per her review of staffing nurses on the 9/29/2025 12:00 AM and 7:00 AM shift had three (3) patients, instead of one (1) nurse to every two (2) patients as the acuity ratio required. The Manager stated she was aware of the staffing issues from 7:00 AM to 12:00 PM shift and made efforts to call and blast text staff to work with incentives but did not have any success. Review of facility policy on guidelines for practice in critical care identified that Frequency of head-to-toe adult ICU systems assessment will be performed and documented in ICU level of care patients every four hours (00:00, 04:00, 08:00, 12:00, 16:00, 20:00)”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50059 Based on a review of medical records, hospital documentation, and staff interviews, for one of three patients (Patient #198) reviewed for change in condition, the hospital failed to ensure nursing staff appropriately escalated care concerns regarding the patient’s continued decompensating respiratory status. The patient was reintubated (a tube placed in the trachea to assist with breathing) after nine hours of labile respiratory status. The finding includes: Patient #198 was admitted to the hospital after a motor vehicle accident with diagnoses of intracranial bleed and respiratory distress, four fractured ribs, and a fractured femur. The patient was intubated in the emergency room and transferred to the intensive care unit (ICU). Review of the patient’s record dated 9/28/2025, identified that Patient #198 was extubated (breathing tube removed) at 10:46 A.M and was placed on 6 Liters of oxygen via nasal cannula. The RN documentation dated 9/28/2025, identified that at 1:45 PM-2:10 PM, the patient’s oxygen levels decreased to 81-88% (normal 94-100%), requiring an increase in oxygen delivery to a 50 % venti mask. At 6:55 PM, the patient’s oxygen saturation was 85% and the patient was placed on a 15-liter non-rebreather mask, then changed to a 15-liter OxyMizer (specialized oxygen nasal cannula). The nurse’s progress note dated 9/29/2025, at 7:11 AM, identified that Patient #198 was confused throughout the night, tachypneic, with shallow, abdominal breathing, difficult to oxygenate, with episodes of desaturation, long periods to recover, weak, ineffective cough, and was maintained on high flow nasal cannula. At 7:35 AM, Patient #198 desaturated to the 70s, was manually ventilated, placed on a Continuous Positive Airway Pressure mask (CPAP) (helps with breathing by keeping the airway open), and ultimately reintubated. The medical record also identified that the patient failed CPAP and needed manual ventilation to increase saturations via the endotracheal tube. Interview with Registered Nurse (RN#160) on 10/1 /2025, at 10:30 AM stated that on 9/28/25, she cared for patient #198 from 7:00 PM to 11:00 PM. RN#160 revealed that the patient was restless and agitated, and frequently removing the nasal cannula. The RN stated she contacted the surgical resident (MD#161), and a non-rebreather (NRB) mask was ordered. She further identified that she made multiple calls to MD#161 regarding the patient’s respiratory status, and the Physician stated that the patient was to remain on the NRB. The RN stated that the patient was maintained on the NRB when she reported off to the night shift nurse. In an interview with RN#161 on 10/ 1/2025, at 11:20 AM the RN stated he assumed care of patient # 198 at 11:00 PM and revealed that the patient was restless, agitated, and confused at times, pulling off the oxygen and desaturating. RN#160 stated he called the surgical resident many times, and the patient was changed to high-flow oxygen with an Oxymizer. RN#161 stated he called the MD#161 about 3:00 AM to make him aware that the patient’s oxygen level had dropped to 66% and the patient at this time needed to be manually ventilated with a bag valve mask. RN#161 stated the MD#161 arrived immediately to at the unit and wanted the patient left on high flow oxygen 60 liters, as the patient’s oxygen levels improved with manual ventilation. RN#161 stated that blood was drawn, including arterial blood gases, and that the results were reported to MD#161. RN#161 stated the patient had labile oxygen saturations for the remainder of the night shift and needed to be manually ventilated 2 more times. RN#161 stated that the day shift surgical resident (MD#164) arrived on the floor, ordered continuous positive airway pressure (CPAP); however, the patient was unable to maintain his/her oxygen levels on CPAP, leading to reintubation at 8:22 AM. RN#161 further stated that the charge nurse and the nurses on the unit were aware of the patient’s status, and revealed that he was not comfortable escalating his concerns to the intensivist, as the surgical resident was available and aware of the patient’s status. Review of the Policy Chain of Command for the Management of Patients dated 11/2024 directs, in part, that the chain of command is the formal line of authority, communication, and responsibility within an organization. Hospital staff is expected to utilize the chain of command to fulfill their duty to advocate for the patient when they have concerns regarding patient safety or any questions regarding patient care. Hospital staff bear significant accountability for interviewing when it appears that decisions and judgments are not consistent with the standard of care.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 14216 Based on clinical record review, hospital documentation, policy review and staff interviews for 1 of 3 sampled patients reviewed for abuse, (Patient #42) the hospital failed to protect the patient from verbal abuse and multiple staff members failed to immediately report the witnessed abuse in accordance with hospital policy. The finding includes: 1. Patient #42 presented to the Emergency Department on 12/13/23 with confusion and the inability to care for self. The patient was admitted for acute delirium and a urinary tract infection. Review of the psychiatric consultation note dated 3/18/24 at 2:28 PM noted an evaluation had been requested because the patient continues to lack insight regarding why the patient is in the hospital, continues to be upset over not being discharged and the hospital is pursuing conservatorship of person and estate. The note identified the patient continues to have agitation, was attempting to leave the hospital and refusing medication and care. The physician’s progress note dated 4/17/24 at 10:27 AM identified intermittent refusal of medications, agitation, uncooperative with care and continues to demand to leave the hospital. Review of hospital documentation dated 4/17/24 at 8:00 PM noted at the change of shift (7:00 PM) patient #42 became upset about the noise of the call bells and started to scream to turn them off. The documentation noted that RN #45 went to the patient’s room to calm the patient, but the patient became more agitated and started screaming profanities at RN #45. The documentation noted the RN left the patient’s room and the patient went to the nursing station, continued to scream and RN #45 used profanities at the patient and gestured her middle finger towards the patient. The documentation noted that at that point patient #42 was assigned to another nurse for care. Review of hospital documentation dated 4/17/24 noted RN #45 was removed from patient care and the patient care area at 9:00 PM. Interview with RN #43 on 4/19/24 at 11:30 AM stated that at the change of shift while she was going to discharge another patient she observed RN #45 yelling/shouting at patient #42. RN #43 stated that she did not separate the staff from the patient because she was doing a discharge and did not want to get involved and was hoping it would stop. RN #43 stated that at the start of the shift she told RN #45 not to take patient #42 because the RN was upset and the patient had outbursts, but RN #45 took the patient anyway. Interview with RN #44 on 4/22/24 at 10:45 AM identified that the call bells were going off at the nursing station and patient #42 was yelling. RN #44 stated that RN #45 got up from the nursing station and stormed into the patient’s room and she could hear yelling from the patient. RN #44 stated that the patient came out of their room and was near RN #45 and she heard RN #45 use profanity towards the patient. RN #44 stated that she then witnessed RN #45 gesture her middle finger towards the patient and she took over patient #42’s care at that time. RN #44 further indicated that she did not know how to handle the situation or what to do so she texted her Director at home to tell her what she witnessed. Interview with RN #46 on 4/23/24 at 10:35 AM indicated that although she was not at the nursing station, she could hear patient #42 and RN #45 yelling at each other. Interview with RN #48 on 4/23/24 at 1:00 PM indicated that although she was in another patient’s room, she heard RN #45 yelling back and forth with patient #42. RN #48 stated that when she came out into the hallway, she witnessed RN #45 stick her middle finger up in the air. RN #48 stated that she did not report what she heard and witnessed because she was focused on a new patient she just received. Interview with RN #50 on 4/24/24 at 10:00 AM indicated that she heard RN #45 yelling and swearing at patient #42. RN #50 stated that she did not report this to the RN Supervisor, she just continued with her assignment. Interview with Director #24 on 4/23/24 at 1:30 PM indicated she received a text from a RN working at the hospital at 7:30 PM to report she observed RN #45 yelling, swearing, and sticking her middle finger up at the patient. The Director stated although she directed the RN to notify the supervisor what happened, she called the supervisor at 8:30 PM to report what was told to her by the RN. Interview with RN #49 (Supervisor) on 4/24/24 at 11:00AM stated that she received a call from the Director around 8:30 PM telling her that there was yelling, screaming, use of profanity and gestures between patient #42 and RN #45. RN #49 stated that she immediately went to the unit and spoke to RN #44 about what she witnessed and was told that RN #45 was yelling, swearing, and gestured using her middle finger towards the patient. RN #49 stated that she removed RN #45 from patient care and spoke to her about what happened. RN #49 stated that RN #45 admitted to putting her middle finger up at the patient as she was walking away but could not recall what she said to the patient. RN #49 stated that she placed RN #45 on administrative leave and walked her out of the building. RN #49 further stated that she did not ask the staff who witnessed the incident why they did not report the concerns right away. RN #49 stated that after the RN was removed, she went to assess the patient who was sleeping at that time. Interview with RN #45 on 4/23/24 at 9:05 AM indicated that the patient’s sitter reported that the call bells ringing was upsetting the patient and RN #45 said “here we go again.” RN #45 stated that she remembers sticking her middle finger up at the patient while in the hallway but could not remember what she said to patient #42. RN #45 stated that when she came in and saw that she was assigned patient #42, another nurse asked her if she wanted to switch, and she said no. RN #45 stated that after the interaction with patient #42 she continued with her assignment and assessed and administered medications to two (2) patients before she left the building. Interview with the Interim Chief Nursing Officer (CNO) on 4/19/24 at 12:10 PM stated that the RN Supervisor reported to her that there was an altercation between a patient and staff member and the staff was sent home. The CNO stated that witnessed abuse should be reported to the supervisor on duty immediately. Review of the hospital policy for abuse, neglect and harassment identified any form of suspected abuse, neglect or harassment allegations regarding a patient will be immediately reported to a manager, supervisor, or director, and as soon as the allegation is known, to ensure the safety and well-being of those involved, the employee will be removed from patient care and patient care areas.”