Report threatened Tenet/SVH with its most severe sanction – termination of any funding for the care of patients under Medicare and Medicaid, calling for corrective action plan to restore safety
In June, the Joint Commission issued findings that Tenet failed to meet care standards set forth in its corrective action plan as documented in complaint filed by MNA
CMS findings validate hundreds of claims made by nurses over the last 18th months about unsafe care conditions and harm to patients caused by policies of embattled hospital CEO and CNO
Nurses also report illegal firing of SVH nurse and local union leader for comments she made on podcast about the patient safety crisis, file suit in Superior Court under Healthcare Whistleblower Statute
WORCESTER, MA — In the wake of six official complaints by nurses at St. Vincent Hospital to state and federal regulators over the course of 2024-25, and several hundred documented cases by nurses of situations that compromised the health and safety of patients under their care, the Department of Public Health in conjunction with the Centers for Medicare and Medicaid Services completed an unannounced investigation of the hospital earlier this year that has validated and substantiated ALL of the nurses’ concerns. The investigation found that St. Vincent Hospital and its administration exposed “all patients at the hospital” to “immediate jeopardy” for serious harm. The investigation documented at least three patient deaths related to lack of needed RN staffing, the lack of monitoring for patients that necessitated immediate intervention by a team of staff to prevent their demise, and the lack of staff supplies and protocols that contributed to more than 200 patients suffering debilitating, preventable pressure ulcers. Through a request under the Freedom of Information Act, the MNA obtained a copy of the full report and will make it available to the media upon request to David Schildmeier at dschildmeier@mnarn.org.
The deficiencies identified in the report were so severe and widespread that the agencies threatened Tenet with termination of CMS funding for all services for patients covered under Medicare and Medicaid, which represent more than 70 percent of the patients served by the facility. The termination of participation in the CMS program is among the most severe penalties the regulator can administer to a provider.
The report and the DPH threat to terminate participation in the Medicare/Medicaid program was issued to the hospital in early February, which was followed by an announcement of the resignation of the hospital’s embattled CEO Carolyn Jackson, who was to leave on Feb. 14th. Jackson’s controversial Chief Nursing Officer, Denise Kvapil, who the MNA believes is the architect of the dangerous staffing practices and failed protocols that imperiled all patients admitted to the hospital, was also let go on the same day.
“While we continue to be both saddened and sickened by the suffering our patients suffered at the hands of these failed and disgraced administrators of St. Vincen Hospital, we felt wholly vindicated in the findings of the recent DPH report, as it validates every single claim we have made over these last two years in our effort to hold Tenet accountable for their failure to value our dedicated staff and to protect the patients we have given our career’s to serve,” said Marlena Pellegrino, longtime nurse at the hospital and co-chair of the nurses local bargaining unit with the Massachusetts Nurses Association (MNA).
Tenet Retaliates Against SVH Nurse, Who Was Key Leader and Whistle Blower in Effort to Expose Unsafe Conditions
In a related event officials at Dallas-based Tenet Healthcare ordered the firing of Carla LeBlanc, RN, one of the leaders of the nurses’ local union with the MNA at the hospital for comments she made on a local podcast shortly after the announced departure of Jackson about the poor patient care conditions including the deaths of patients under nurses care – the very conditions and incidents validated independently by the DPH. Though the interview occurred in early February, it wasn’t until April 30th, three months after the fact, that LeBlanc was fired at the direction of officials, not in Worcester, but from Tenet’s corporate offices in Dallas according to information received by the MNA. LeBlanc was also quoted and photographed by the Boston Globe in a frontpage story in late December of 2024, reporting on two patient deaths and other incidents documented in the nurse’s sixth complaint to DPH and other agencies, and further verified by the family of a patient who died, and nurses who were on duty for those incidents. LeBlanc, in an effort protect her patients, had also filed a number of complaints to DPH, as well as dozens of reports to hospital management about conditions that jeopardized the safety of her patients.
“As a nurse and a union leader, I have a professional and ethical responsibility to advocate for my patients and to do whatever is necessary to protect them from harm,” said LeBlanc in response to her termination. “While frustrated and angered by Tenet’s corporate decision to terminate my employment, I intend to fight this decision in my continued effort to stand up for what is right and just, not only for me, but more importantly, for all nurses who choose to stand up and speak out against unsafe working conditions that threaten the safety of the patients we have given a solemn oath to serve.”
In response to the firing, the MNA has filed a charge of unfair labor practice with the National Labor Relations Board and last week filed suit in Worcester Superior Court against Tenet Healthcare under the state’s Healthcare Whistleblower statute, which is designed to protect caregivers, including nurses from being fired or any retaliatory action by their employer for disclosing any activity, policy or practice of the facility that is in violation of professional standards of practice that poses a risk to public health. This lawsuit would follow one filed last year in the same court over the firing of eight other SVH nurses for their efforts to document unsafe patient care conditions in the first complaint to state and federal agencies. Reporters who wish to receive a copy of both Whistleblower complaints should contact David Schildmeier at dschildmeier@mnarn.org.
Key Findings of DPH/CMS Report
Every hospital that receives reimbursement for the care of patients covered under Medicare and Medicaid must meet standards of care that are designated “Conditions of Participation” in the program. One of those conditions relates to the provision of nursing care, specifically: “The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse.” (see page 6 of the DPH report)
The DPH/CMS report found that Tenet/SVH failed to meet that condition, stating:
“Based on interviews, documents reviewed, and records reviewed, the Hospital failed to ensure adequate nursing staff were available for the care of all patients in the Hospital.” (page 7 of report)
The report further states:
“Immediate Jeopardy (IJ) was identified on 2/4/2025, regarding the Condition of Participation (CoP) of Nursing Services for failure to ensure adequate numbers of licensed registered nursing staff were available to provide nursing care to meet the needs of patients. Due to a lack of nursing staff and ancillary nursing staff, Hospital nurses were given multiple tasks resulting in patients not receiving monitoring as ordered nor necessary care.” (see page 8 of report)
As part of these investigations, the DPH will often randomly pull a number of patient records and in the case of SVH out of a sample of 21 records, they identified five patients who suffered preventable, serious harm, including three deaths directly attributable to understaffing of nurses that prevented the timely monitoring and care required. This included:
- The death of patient “who was not monitored by nursing staff while ordered for telemetry monitoring (a monitoring system used to continuously monitor a patient’s heart rate, rhythm and other vital signs) and was subsequently discovered to be cyanotic (a blue or purple discoloration of the skin due to low levels of oxygen in the blood) with a low heart rate of 39 and unrecordable blood pressure.” (see page 7 and 14 – 18 of report) While the report cites the Director of Critical Care, Cardiac Telemetry and Wound Care who said the expectation of the staff member tasked with monitoring Telemetry is that they have no other responsibilities, the RNs on the unit that night reported “there was not a dedicated staff member to monitor the telemetry monitors and the overnight shift made the staffing office aware that there were no staff available to monitor telemetry on the day shift.” (page 16-17 of the report) The lack of staff to monitor telemetry patients was a regular occurrence according to the nurses, and as in this case, requests to management to address the situation most often went unheeded, making a preventable death like this one inevitable.
- Patient with a tracheotomy assigned to Progressive Care Unit experienced respiratory crisis because the patient “was not monitored by nursing staff while ordered for telemetry monitoring and subsequently found to be hypoxic (low oxygen levels) with an oxygen saturation in the 80’s and an elevated heart rate requiring intervention by a Rapid Response (a system where a team of providers is summoned to the bedside when a patient is showing signs of clinical deterioration). (see page 7 and 19 of report) As with the patient who died as a result of the lack of staff to perform appropriate telemetry monitoring (see previous bullet), this patient almost suffered a similar fate because, according to the report, “the Director of Nurses for the second floor indicated that the day shift had a call out resulting in unit having no staff to monitor telemetry.” (see page 21 of report) According the report, “the Chief Nursing Officer (CNO) said the Hospital has not been able to meet the staffing grid for nurses.” (see page 21 of report) In addition, the nurse assigned to the patient had no experience in caring for a patient with a tracheotomy, “who had indicated that this was her first day off orientation and confirmed that they did not have a staff member to monitor Telemetry that shift, and the monitor at the end of the unit wasn’t working.” (see page 20 of report)
In fact, based on one of the MNA’s previous complaints to DPH, the hospital was cited in April, as reported by MassLive, for its failure to provide appropriate telemetry monitoring, including providing appropriate telemetry boxes to monitor patients who have been admitted for serious cardiac conditions. - The death of a patient who “was not monitored by an RN during transport from the Emergency Department to the telemetry unit nor was a nurse-to-nurse hand-off completed as required by Hospital policy upon the patient’s transfer. The patient was discovered to have decreased respirations and low heart rate for an unknown period of time.” (Page 7 and 36 – 39 of report) The report detailed that patient who was evaluated in the ED, was being transferred to the hospital’s telemetry unit, where the physician had ordered immediate and continuous telemetry monitoring for the patient. In such cases, the patient was to be accompanied by a nurse to the unit with monitoring already started, and then for that nurse to execute a direct “nurse to nurse” handoff of that patient to ensure proper care was administered. This never happened. The patient was transported to the unit without a nurse and left in the hallway unattended. By the time the nurse on the floor got to the patient, the patient was experiencing a respiratory crisis, gasping for air, necessitating the call for a rapid response team to save the patient. The patient died shortly thereafter. The report included testimony by nurses that the movement of patients from unit to unit without proper hand-off procedures and staff was a common occurrence. (see page 37 – 39 of report) (According to the MNA, CNO Kvapil had cut staffing in the ED by more than 40 percent, making it harder for a nurse to leave the unit to accompany a patient being transferred to another unit. She also had changed the hospital’s protocol for the handoff of patients so that direct nurse-to-nurse communication upon arrival on the unit was no longer required.
- The death of a patient who “did not receive Continuous Veno-venous hemodialysis (CVVHD) for fluid removal as ordered, received Hemodialysis (HD) outside of Hospital policy timeframes, and was not able to receive his/her full HD treatment for fluid removal.” (see patient 7 and 30-35 of report)This patient was admitted to an understaffed intensive care unit, which was unable to provide the one-to-one nursing care for a patient in that condition called for under state law. The unit also lacked a nurse trained in administering dialysis treatment that the patient required. According to the report, an ICU physician on the unit “said there was not sufficient support in the ICU RN staffing to perform CVVHD for Patients as CVVHD requires a RN to care for a patient 1:1.” (see page 33-34 of report) The Critical Care Director pointed to the administration’s failure to ensure staffing for the shift, stating she “had been trying to find RN coverage for the night shift for the ICU… but was unable to get RNs in due to not having approval for a shift pick up bonus.” (see page 34 of report) Due to the chronic staffing shortages, the MNA had been advocating for the hiring of travel nurses and to institute shift bonuses to entice staff to pick up extra shifts, but Tenet refused to support and implement a shift bonus program.
- The DPH/CMS report also cited an incident of a patient suffering a debilitating pressure ulcer, and referenced testimony provided and documented by nurses of more than 200 incidents of patients experiencing pressure ulcers. (See page 7 – 8 and 22 – 27 for report) The issue of inadequate staffing and unsafe RN to patient ratios is a major cause of high numbers of pressure ulcers. The report includes testimony from a wound nurse, stating “pressure ulcers/injuries have been occurring at the Hospital, many of which are preventable. She said staffing ratios for RNs working on the inpatient units have been too high and interventions such as repositioning and incontinence care are not happening. She said often supplies are not well stocked on the inpatient units and nursing staff need to look for supplies from other inpatient units. She said minor pressure injuries are developing into stage 4 pressure injuries while patients are inpatient in the Hospital. She said there are not enough cameras on the inpatient units for capturing pictures of wounds for monitoring of patients’ wounds.” (see page 25 of report) The report cites the actual staffing levels on the telemetry unit for a patient suffering a severe pressure ulcer. “Review of the telemetry unit schedule (24 North) for day shift on 12/8/24 indicated a census of 23 patients on the unit with five RNs on the schedule (four with patient assignments and one monitoring the telemetry system) and two Patient Care Assistants. Review of the Hospital’s staffing guidelines for the telemetry unit indicated a total patient census of 23 patients would require seven RNs and three PCAs to be staffed during the day shift.” (see page 25 of report).
In addition to citing the hospital’s failure to provide appropriate RN staffing as a condition of participating in the Medicare program, Tenet/St. Vincent was also cited for a system-wide failure to properly implement and manage a Quality Assessment and Improvement Program to ensure the safety of its patients. The DPH highlighted the administration’s failure to implement such a program to prevent the epidemic of pressure ulcers, stating: “the Hospital failed to ensure the Quality Assessment and Performance Improvement (QAPI) Program implemented an effective, ongoing, hospital-wide, data-driven quality assessment, and performance improvement program to reduce the prevalence of Hospital Acquired Pressure Injuries.” (page 2 of report)
In Response to Care Deficiencies, DPH Threatens Tenet with Termination of CMS Contract for Medicare/Medicaid Patients
As result of the investigation, and all the deficiencies identified in the report, the document includes a letter to the CEO of Tenet/St. Vincent Hospital with the following order:
Within ten calendar days of receipt of this letter you must submit an acceptable Plan of Correction (the POC) for each deficiency cited in the Statement of Deficiencies (the SOD). The Facility is currently on a 90-day termination track, with a termination date of March 30, 2025, resulting from EMTALA survey: OM4Q11 and a CoP survey: S08J11, with IJ removed for Emergency Services in which notification was sent by the Centers for Medicare and Medicaid Services (the CMS) on December 30, 2024. All deficiencies cited must be corrected no later than March 22, 2025.
The “termination track” referenced in the letter refers to the threat by CMS of the termination of the hospital’s contract with CMS to be reimbursed for the care of patients covered under Medicare and Medicaid. The report includes specific corrective actions required to prevent termination, and steps the SVH administration promised to take to prevent further incidents of harm to patients.
MNA Documents Tenet’s Failure to Follow Corrective Action Plan Resulting in Joint Commission Finding of Tenet’s Failure to Meet Promised Changes
The nurses have reviewed the corrective plan contained in the report and found that a number of those remedies have not been implemented. On May 12, the MNA submitted a follow-up complaint to the DPH/CMS, as well as the Joint Commission (the body that oversees accreditation of acute care hospitals) detailing Tenet’s failure to ensure there is compliance with the DPH/CMS order for change to prevent patients from being placed in immediate jeopardy going forward, writing:
In many or most cases, St. Vincent Hospital (SVH) management has not effectuated the corrective actions submitted to state/ federal regulatory agencies after multiple days of DPH/CMS investigation identified safety concerns. SVH management continues to fail to protect the safety and well-being of patients in their care.
On June 25th, the Joint Commission responded to the MNA complaint and after its investigation concurred that the hospital had failed to meet its obligations under the corrective action plan, “which will require the organization to demonstrate evidence of compliance to be compliant with applicable The Joint Commission standards and CMS Conditions.”
Reporters who wish to receive a copy of the MNA’s letter detailing Tenet’s failure to implement promised corrective actions, as well as the communication from the Joint Commission to MNA in response to the complaint should contact David Schildmeier at dschildmeier@mnarn.org.
SVH Nurses’ Effort to Voice Patient Safety Concerns Finally Vindicated
Under the leadership of Jackson, and her chief lieutenant Kvapil, the nurses at St. Vincent Hospital were subjected to an unrelenting assault on their ability to provide the care they knew their patients deserved, yet the nurses were equally unrelenting in their effort to document and report what they and their patients were experiencing to all responsible state and federal agencies In December 2023, January, March, April, May and December of 2024, the SVH nurses and MNA filed a number of official complaints with the Department of Public Health Division of Healthcare Quality, Joint Commission (which accredits acute care hospitals), the Center for Medicare and Medicaid Services and the Mass. Board of Registration in Nursing in response to a growing and dire crisis in the safety of care for patients admitted to the Worcester-based facility. In September, the nurses also filed a complaint against Tenet-owned Framingham Union Hospital citing similar deficiencies in care.
In late December the Boston Globe ran a frontpage story about the last of those complaints, and reported on two patient deaths identified in the complaint, which was verified by the patients’ family members and the nurses who filed the reports with DPH. The story also highlighted the nurses’ call for a meeting with DPH Commissioner Robbie Goldstein, so they could directly share what they and their patients were experiencing. That meeting was held in early January. The Globe story on the Goldstein meeting provided more information voiced by nurses about the untenable conditions at the hospital, with the Globe citing the Commissioner’s characterization of what he heard including, “the stories and insights highlighted by these frontline caregivers were honest and heartfelt. Their perspectives are invaluable, as nurses are so often the first to identify potential risks and problems.”
Tenet characterized the nurses concerns as “unfounded” and a “publicity stunt,” two claims proven to be truly unfounded given the findings of the DPH/CMS investigation.
Nurses Had Hoped for New Opportunity for Meaningful Change with Departure of Jackson et al.
After the departure of CEO Jackson and CNO Kvapil, and the installation of a new CEO for St. Vincent and other Tenet hospitals in Massachusetts, along with the hiring of a new head of human resources, and local labor relations chief, the MNA nurses were hopeful that Tenet was indeed turning a new leaf. It appeared that might be the case, as nurses and the new management team began efforts to build a more productive relationship. But the initial shine of the new relationship was tarnished with the decision by officials in Dallas to target Carla LeBlanc and the realization by the nurses that Tenet has failed to make the corrective actions it promised the DPH and CMS to ensure the safety of all patients and to avoid having their CMS contract terminated.
“We are always ready and willing to work in good faith with this or any administration that acts in good faith with us to ensure the safety of our patients, but once again, Tenet is showing its all too true colors and we, as we have always done, will not hesitate to hold them accountable,” Pellegrino concluded.
