Mission sets 10-minute goal for emergency patient care, document obtained by Watchdog shows

by Andrew R. Jones, avlwatchdog.org

Mission Hospital has enacted drastic operational changes, including rapid turnaround time goals for emergency department patients and their lab work and enhanced communication procedures, all as state investigators have returned to the Asheville facility this week following recent federal findings of serious deficiencies and immediate jeopardy.

Patients should be seen, triaged, and assigned to a nurse within 10 minutes under new policies that also press for lab orders to be collected within 30 minutes, according to internal hospital documents obtained Feb. 20 by Asheville Watchdog.

N.C. Department of Health and Human Services (NCDHHS) investigators visited HCA Healthcare-owned Mission on Feb. 20, according to two hospital sources who spoke on the condition of anonymity out of fear of retribution, and communications obtained by The Watchdog. It is unknown how long the investigators will be at the hospital.

Mission and HCA spokesperson Nancy Lindell did not immediately respond to The Watchdog’s questions about the changes in procedures, the visit or what will happen next. NCDHHS also did not immediately respond to questions.

One Mission document, titled “ED Focused Plan of Correction: ER Leadership Review,” contains 10 action plan items. All the items directly correlate to deficiencies outlined in a 384-page report from the U.S. Centers for Medicare & Medicaid Services (CMS) obtained by The Watchdog on Feb. 15. That report described long waits in the emergency department, significant delays in lab work, and neglect that led to the deaths of four patients and injury to others.

The internal document obtained Feb. 20 by The Watchdog is part of the practical application of a plan of correction that Mission must create and follow or risk loss of its Medicare and Medicaid funding after it was placed in immediate jeopardy by CMS. Mission has until Friday to get the hospital out of immediate jeopardy, the most severe sanction a hospital can face.

The document informs staff that:

• All emergency department patients must receive an initial pain assessment.
• Heart signal monitoring for patients whose care was ordered by a doctor should be completed within 10 minutes.
• Labs should be collected within 30 minutes of the order.
• Patients arriving at the emergency department must be seen, triaged and have their care assumed by a registered nurse within 10 minutes. This includes patients who are on an EMS stretcher, even if they are not immediately assigned rooms.
• For patients who need heart monitoring through telemetry, nurses or whomever is delegated, have 30 minutes from the time the telemetry order is placed to begin cardiac monitoring for such patients.
• Patients experiencing alcohol withdrawal must have a completed specialized assessment, known as a CIWA, within an hour of their arrival and begin treatment as soon as possible to reduce the severity of their withdrawal symptoms.
• When patient needs are escalated to another provider outside the emergency room, closed-loop communication must be used. Closed-loop communication is when the person receiving instruction or information repeats it back to ensure the message is understood correctly, and the sender confirms to “close the loop.”
• The timely execution of radiology orders ensures that providers are given important information to make decisions in the best interest of patients.
• All pediatric patients should have an informed consent-to-treat on file.
• A ligature is defined as anything which could be used for the purpose of hanging or strangulation. Ligatures pose a risk for patients who may be suicidal.

In addition, the hospital has provided emergency department nurses cheat-sheet style pocket guides to follow the action plan items, as well as instructions on how to interact with NCDHHS investigators.

“This is your chance to shine,” reads one document, which tells nurses:

• “Assist unit in completing survey unit readiness checklist
• Greet surveyors with name and title
• No food or drinks in patient care areas
• If you don’t know the answers say, ‘I am not sure, let me find that information for you’
• Policies, personnel files, or printouts of the patient record should be requests and provided through survey support team”

NCDHHS investigators last visited the hospital for three weeks in November and December. They found nine deficiencies between April 2022 and November 2023 and several instances that led to immediate jeopardy, the most serious sanction a hospital can receive.

According to several nurses who work in Mission’s emergency department and who are members of its nurses union, the hospital has changed many procedures since early January, around the same time The Watchdog was the first to report that NCDHHS recommended to CMS that the hospital be found in immediate jeopardy.

In fact, during the time of the NCDHHS inspections, hospital leadership sent an unusual email to all medical staff, The Watchdog revealed, informing it of seemingly obvious expectations in the emergency department, including a need to respond when alerted to a patient’s loss of consciousness or “emergent” condition, and to stop to stabilize patients at risk of dying.

The Watchdog had reported in August 2023 on nurses’ concerns that the hospital’s lax emergency department transfer procedures were endangering patients. For two years, the nurses had sent formal complaints to NCDHHS, but as The Watchdog reported, the agency had not sent investigators to the hospital, citing staff shortages.

Months later, Mission changed some of its procedures to require phone calls during handoffs, which the nurses had previously requested.

State investigators visited Mission soon afterward. They found failures in hospital leadership as well as problems with patient handoff procedures and other communication failures.

“The hospital’s leadership failed to ensure a medical provider was responsible for monitoring and ensuring the delivery of care to patients presenting to the emergency department,” the CMS report stated.

Hospital leadership also “failed to ensure emergency care and services were provided according to policy” and “failed to ensure adverse events were documented, tracked, trended, and analyzed in order to implement preventive actions and identify success of actions taken,” according to the report.

Leadership and other issues were connected to system-wide breakdowns and the deaths of four patients: one who died after a bag of medication ran dry, two who died after his labs were delayed; one who was left alone in a hallway bed.

One patient who did not die had labs delayed for hours as he suffered from alcohol withdrawal, according to the report. He waited in the emergency room for nine hours, and during that time he suffered a seizure and fell, wounding his head.

‘Band-Aids on a gunshot wound’

The changes have brought pressure on nurses who say they are being micromanaged. Some are being asked to sign forms about care they gave patients weeks ago. Others are being told by management that even the smallest mistake will mean huge setbacks for the plan of correction, they say.

Still others are worried that, once surveyors leave and the pressure following the immediate jeopardy dissipates, HCA and Mission management will continue to staff the emergency department below what is needed.

“I know it’s temporary,” Jennifer Gibson, an emergency department registered nurse and union member, told The Watchdog in a Feb. 5 interview. “It’s discouraging because I know in my heart that … it’s going to go right back to ‘the war zone,’ as we call it.”

Jacob Rhea, also an emergency department registered nurse and union member, said he feared the implemented fixes could be temporary and that Mission needed ultimately to focus on hiring more full-time employees.

“All of the nursing staff at Mission ER, we want to actually have a better solution,’ Rhea said in a Feb. 6 interview. “We want to be able to provide the care that people need. But the way that they’re going about it is they’re trying to put Band-Aids on a gunshot wound.”

Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Andrew R. Jones is a Watchdog investigative reporter. Email arjones@avlwatchdog.org. The Watchdog’s reporting is made possible by donations from the community. To show your support for this vital public service go to avlwatchdog.org/donate.