The action comes in the wake of unannounced inspections at the hospital by the State Department of Public Health.

Besides discovering problems with sores and medication, investigators examined two cases of bodies in the hospital morgue that weren't adequately indentified.

DPH had already conducted a separate investigation prompted by the 2005 death of a 21-year-old patient from an overdose of potassium chloride administered by staff.

This time DPH found two new, less serious, cases in which patients were given non-lethal overdoses of medication.

So this month DPH Commissioner J. Robert Galvin fined the 511-bed hospital $12,000 for continued problems. That's on top of an $18,000 fine levied in 2006.

DPH also drew up a new consent order to modify the one St. Raphe's entered last year.

Hospital President David Benfer (pictured above) signed the modified consent with DPH on Jan. 3, promising to bring about systemic changes.

Click here to read the modified consent order, details of the DPH investigation, and the previous consent order. Its issuance was first reported Monday by the Hartford Business Journal.

St. Raphael's has already taken most of the steps called for in the new order since the original DPH inspections, Vice-President and General Counsel Janeanne Lubin-Szafranski said in an interview Wednesday morning.

She said the hospital is in the process of completing the rest.

"This hospital is committed to our patients," she said. "We will do whatever it takes to create a safe, caring environment for them."

Lubin-Szafranski welcomed DPH's plan. "Their breadth of experience gives us opportunity to improve, which we're always looking to do. Health care is not a static business."

DPH spokesman William Gerrish said DPH is more interested in prodding hospitals to change policy than to punish them. People sometimes ask why the agency doesn't levy higher fines in these cases. "We are in hospitals and nursing homes a lot," he said. "We take these actions to ensure patient safety." Click here to review similar cases on the DPH website, including a Jan. 17 finding against Waterbury Hospital and cases last August against Norwalk Hospital and Lawrence and Memorial Hospital.

St. Raphe's has been cooperative with the agency in this process, Gerrish noted.

Among other measures, the hospital has 14 days to review its "policies and procedures" for administering and monitoring medication to patients. It has 21 days to start having a licensed pharmacist go along on staff rounds, train staff on administering medication, and complete audits. The hospital must also hire a nurse from a company called Independent Wound Care Nurse Consultant (IWC) to look at the wound care program and suggest improvements.

The hospital signed a contract this past Friday with the nursing consultant, according to Lubin-Szafranski. It has been training doctors, nurses and other staff on procedures for modifying doses of medication. And it reexamined "all the different kinds of techniques we have to skin assessments, to look at mattresses, ointments and medications, turning protocols," she said.

Titration Situation

The agreement stems from unannounced checks made at the hospital by DPH investigators.

One set of visits took place last June 5-7.

DPH investigators concluded that the hospital needed to change policies on "titration" -- the process of gradually adjusting a patient's medication.

In random checks in early June, DPH investigators found patients being administered medication without clear instructions about how much to give them, according to the findings DPH published along with its consent order.

"Patient #7" was receiving an hourly intravenous morphine drip to treat; the patient suffered from congestive heart failure, pneumonia, and respiratory failure. "Patient #14," suffered from a brain injury caused in an auto accident. "Patient #3" came to the hospital with acute respiratory failure, was receiving Fentanyl. Doctors had failed to detail the dosage each patient was supposed to receive during the day. Other patients in a similar situation were being treated for alcohol withdrawal and diabetes.

Investigators also found patients receiving oxygen or IV medication not "in accordance with physician's orders and/or hospital policy."

Basically, DPH decided that doctors were not writing orders with specific enough instructions -- exact doses, exactly how often nurses should administer them, when to change the doses, often involving pain control. A physician would write directions along the lines of "Titrate to comfort," Lubin-Szafranski said. The state wants more specific written instructions, she said: "Here's the increment, here's the dosage range, here are the indicators for giving that..."

A separate set of concerns involved pressure sores, including (but not only) bed sores.

Investigators found five patients whose pressure ulcers the hospital was failing to "monitor, assess and treat" according to policy.

Nationally, regulators have begun paying more attention to handling of pressure sores, according to Lubin-Szafranski, as increasing numbers of "older, sicker, less mobile people" come to hospitals from nursing homes or private residences. They often have more fragile skin and don't move around. They have longer stays. That has created a need for more attention to managing pressure wounds.

DPH returned in September for another inspection and subsequently drew up the modified consent form for further actions.

The Morgue

On those visits, which took place Sept. 1-3, investigators also found bodies in the hospital morgue without full names or verification that they'd been checked by security. Among the living, investigators found staff uniformed about protocols for dealing with patient falls; the hospital had failed to fully carry out a promised plan to educate nurses on the subject.

Investigators found five patients whose pressure ulcers the hospital was failing to "monitor, assess and treat" according to policy.

"[D]irty pots were discovered in the designated 'clean' area for pots" in the Dietary Department. refrigerators containing medications were set too high.