Unsafe Staffing at St. Vincent Tied to 3 deaths, 200+ Injuries, Federal Probe Finds

Massachusetts nurses are sounding the alarm after a damning state and federal investigation confirmed what St. Vincent Hospital RNs have been saying for years: unsafe staffing and failed protocols have been putting patients at serious risk — and costing lives.

The joint investigation by the Department of Public Health (DPH) and the Centers for Medicare & Medicaid Services (CMS) found that “all patient were placed in “immediate jeopardy” for serious harm. The report documented at least three patient deaths related to lack of needed RN staffing, a lack of monitoring that required emergency intervention to prevent deaths, and a lack of supplies and protocols that contributed to “more than 200 patients suffering debilitating, preventable pressure ulcers.”

The Consequences Could Have Been Massive

The deficiencies 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.” That’s more than 70% of the hospital’s patient population. CMS gave the hospital ten days to submit an acceptable corrective action plan and ordered that “all deficiencies cited must be corrected no later than March 22, 2025.”

Shortly after the findings were delivered in February, “embattled CEO Carolyn Jackson” and “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” as Jackson’s departure.

Nurses: “We’ve Been Saying This for 18 Months”

For more than a year and a half, frontline RNs have been filing official complaints, meticulously documenting unsafe conditions shift after shift. They’ve described assignments so heavy and staffing so short that it was impossible to round appropriately, catch early signs of decline, or give the kind of care nurses know patients deserve.

“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. Vincent 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).

Corrective Plan Promised… but Not Delivered

Despite agreeing to a corrective action plan, nurses say many fixes never happened. In a May follow-up complaint, the MNA wrote: “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 25, the Joint Commission concurred, stating 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.”

Adding Insult to Injury: Retaliation Against a Nurse Leader

In the middle of all this, SVH fired longtime nurse and union leader Carla LeBlanc after she spoke on a podcast about unsafe staffing and patient harm. The hospital claimed her statements were “disloyal, reckless, and maliciously untrue.” MNA calls it blatant retaliation and has filed suit under the Massachusetts healthcare whistleblower statute.

The Fight Isn’t Over

After Jackson and Kvapil’s departure, nurses hoped for meaningful change with the arrival of new leadership. But the decision by Tenet to target LeBlanc — and the failure to implement all promised safety fixes — has renewed tensions.

“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.

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