By Barbara Durr, Asheville Watchdog
Forrest Johnson fell in her garden on April 22 and broke her leg in two places. Her husband and stepdaughter rushed the 68-year-old former nurse to the Mission Hospital emergency room in Asheville from their home near Burnsville, about an hour’s drive. They arrived around 8 p.m.
Having spent 20 years in nursing, Johnson said, “I sort of knew what to expect.” But what she did not expect was that she would lie for nearly six hours in the emergency room without water, ice, a blanket, a pillow to elevate her leg, food, or pain medication.
“I just had a very busy nurse,” Johnson said. The nurse quickly apologized that he would not be able to check on her every 15 minutes, as he normally would be expected to do, she said. Because of understaffing at Mission, “He just didn’t have the time to care for me,” she said.
Lynn Blass of Asheville had surgery at Mission for a broken hip May 10. Unable to get to the bathroom without assistance, she rang the call button for help. And rang and rang. By the time a nurse finally arrived an hour and 20 minutes later, she said, she had already soiled her bed.
Karen Sanders, who holds a master’s degree in nursing and worked at Mission Hospital for 16 years, said she has been “horrified” to witness what she said is a recent decline in Mission’s quality of care. Now a professional patient advocate, Sanders said she has observed a rise in Mission’s nurse-to-patient ratios — meaning each nurse is required to care for more patients than before — and a decline in the number of housekeeping and security workers.
Their stories are just a few of a cascade of complaints from patients, nurses, doctors and other health care professionals interviewed by Asheville Watchdog in recent weeks.
Since investor-owned HCA Healthcare bought nonprofit Mission Health System in 2019, stories are increasingly common of long waits in the emergency room, unsanitary conditions, broken or missing equipment, patients having to lie in their own urine and feces, doctors leaving because of pay disputes and nurses weeping in the hallways because of stress and chronic understaffing.
Cost-cutting or unavoidable shortage?
Critics, including local officials, say the understaffing is a result of HCA’s deliberate cost-cutting, which has contributed to record profits for the Nashville-based hospital chain despite the pandemic. Others say doctors and nurses are quitting Mission because of what they say is HCA’s profit-motivated management.
HCA officials noted that the shortages of registered nurses and nursing assistants are not unique to Mission, but rather a nationwide problem.
Yet complaints of declining patient care and safety began soon after HCA took over. Fifteen months ago, in February 2020, Asheville Mayor Esther Manheimer and Buncombe County Commission Chair Brownie Newman, along with four other North Carolina elected officials, signed an open letter to the independent monitor overseeing HCA’s compliance with terms of the sale, stating, “We are writing with deep concern regarding the state of Mission Hospital Systems since the purchase by Hospital Corporation of America last year.”
“Concerns have been pouring in from distressed patients, practitioners and HCA employees,” the statement said. “With HCA heavily focused on the bottom line, there have been numerous, aggressive staff cuts over the past year, putting patient safety at risk. Certified nurse assistants and unit secretaries have been cut dramatically or eliminated, putting new pressure on nurses. Patient to nursing staff ratios have also increased and some departments have seen an exodus of nurses, further stressing the remaining nurses.”
Contacted last week by Asheville Watchdog, Manheimer said, “I continue to have concerns regarding the level of care provided by HCA.”
None of the patients who shared their complaints about quality of care at Mission with Asheville Watchdog said they blamed the staff. They said they found nurses, doctors and other hospital workers there to be “terrific” and “caring” and highly skilled.
‘HCA came in with a hatchet’
Janet Moore, who left Mission Health in 2011 after 16 years as a senior executive for the hospital system, was back at Mission in October as a patient, for an epidural in her spine. Thirty-six hours later, she developed a serious staph infection, she said.
Although staphylococcus bacteria infections can occur for a variety of reasons, the most serious cases frequently occur as a result of inadequate presurgical skin preparation and instrument sterilization, which Moore said she believes was the cause of her infection.
As a result of the staph infection, Moore then spent six days in an observation unit at Mission, where, she said, “No one cleaned my room.”
Moore said the bedside care and attention she received from Mission doctors and nurses was “tremendous,” but she said staffing cuts affected the quality of care.
“HCA came in with a hatchet,” she said.
In an email to Asheville Watchdog, Nancy Lindell, director of public and media relations for HCA’s North Carolina Division and Mission Hospital, denied that HCA had cut any jobs for housekeeping, security or unit clerks. “We have not reduced nursing staff and are actively hiring,” she wrote.
The Mission Hospital job board recently listed approximately 300 open nursing positions.
“Every hospital across the country is struggling with the recruitment and retention of nurses,” Greg Lowe, president of the North Carolina Division of HCA Healthcare, told an audience at Asheville’s Council of Independent Business Owners on May 7.
Although Mission Hospital is not unique in reporting shortages of nurses and nursing assistants, it was the only local hospital to be downgraded in the latest safety ratings.
In late April, two of the leading national agencies that assess a hospital’s quality of care — including such factors as safety, accidents, injuries, infections and readmissions — lowered their ratings of Mission Hospital.
The Leapfrog Group, an independent agency, downgraded Mission Hospital to “B” from “A.” According to Leapfrog, the hospital fell short in various measures, including blood and surgical site infections, high-risk baby deliveries, some cancer procedures and the experience of patients for elective surgeries.
UNC Health Care’s Pardee Memorial Hospital in Hendersonville, AdventHealth Hendersonville and Duke LifePoint’s Haywood Regional Medical Center in Clyde all retained their “A” grades from Leapfrog for the latest period. All are not-for-profit hospitals.
The Centers for Medicare & Medicaid Services also downgraded Mission to four stars from five. CMS uses surveys of patients’ experiences, including how responsive hospital staff were to their needs and the cleanliness of the hospital environment.
On the lower ratings, Lindell wrote in an email to the Watchdog, “We were disappointed in the report from Leapfrog and CMS and are working diligently to improve.” She said that the hospital is “using the feedback from both of these scores to implement improvements.”
As reported April 30 by Asheville Watchdog, HCA rewards its senior executives with bonuses and stock grants based on a formula weighted 20% on meeting standards for quality of patient care and 80% on hitting profit and share price targets. Critics, including some HCA shareholders, say the formula gives HCA executives an incentive to cut costs, often by reducing payrolls, at the expense of patient care.
A shareholder proposal to study the feasibility of increasing the impact of quality metrics on executive compensation was rejected at HCA’s annual stockholder meeting last month, the company reported.
“HCA Healthcare’s primary objective is to provide the highest quality health care to our patients, and our executive compensation philosophy is centered around creating a strong, positive link between our performance and compensation,” Lindell told the Watchdog. She said executive compensation is determined by the board of directors and is based on comparisons with other comparably sized health care companies.
‘Money is always going to win’
“I think there is an inherent conflict in for-profit hospitals like HCA, which has a responsibility to its shareholders to maximize profits but also has a responsibility for quality patient care,” said Jacob Blass of Asheville, who spent 23 years as a senior executive in the health care industry. “Money is always going to win.”
Blass’ own experience of this conflict at Mission came May 9 when his wife, Lynn, fell off her bicycle and broke her hip. She was taken to Mission’s emergency room in an ambulance, Blass said, and “everyone on the staff level was terrific.” But her stay in the hospital after a successful surgery on May 10 was marred by lapses in medical staff attending to her, Jacob Blass said, including the bathroom incident.
“The reason Lynn had to wait so long was because of the lack of CNAs or other staff,” Blass said, referring to certified nursing assistants.
Blass also said the device intended to assist blood flow in his wife’s legs was broken and not repaired, and when she was discharged from the hospital, the Mission staff didn’t give him any wound dressing supplies or order a bedside commode to be sent to their home, as promised. “Mission gave me zip for home care,” he said.
Forrest Johnson’s six-hour wait for even the most basic care was far above the norm. While wait times in emergency rooms have generally increased in recent years, the average wait time nationally for treatment of those admitted to an emergency room is just over an hour, according to the federal Centers for Disease Control and Prevention.
Her ordeal didn’t end there. “They splinted my leg and sent me home,” she said, recalling that she didn’t think doing so was a wise decision for her care because “I was in so much pain.”
She was called back to Mission Hospital for surgery on the morning of April 24, nearly 36 hours after arriving at the emergency room. This time, Johnson said, her care improved, and she praised the nursing staff and surgeon as excellent. She is now recuperating at home.
An award for nursing excellence
Just six months ago, nurses at Mission won the American Nurses Credentialing Center’s “Magnet” award for nursing excellence. Chad Patrick, chief executive officer of Mission Hospital, touted the award at that time as “tangible evidence of our nurses’ commitment to providing the very best care to our patients, of which we are extremely proud.”
Yet, some nurses at Mission said they do so despite what they described as being undercut and demoralized by HCA management.
Asheville Watchdog interviewed six nurses and two other healthcare professionals at Mission who were willing to talk about what they are experiencing inside the hospital. All of them requested their names not be used, for fear of retribution, including losing their jobs. (See Asheville Watchdog’s policy on anonymous sources and confidentiality.)
All of the health care professionals contacted for this story cited staffing levels as the critical issue for quality of care at Mission. They said there are fewer registered nurses and certified nursing assistants to attend to patients since HCA took over, and fewer administrative assistants, housekeepers and security staff.
Staffing is a key item in initial contract negotiations for National Nurses United, which was elected last year to represent nurses at Mission Hospital despite strenuous opposition from HCA.
As a sign of Mission Health’s deep demand for nurses, it is now offering up to $15,000 in signing bonuses for select nursing roles. It is also trying to lure housekeepers with signing bonuses of up to $1,000, starting a CNA training program to help fill nursing support positions and creating a new training program for first-year nursing graduates to assist with the transition from the classroom to bedside nursing, Lindell said.
“We’re going to have some exciting news about our own plans” to address the nursing shortage, Lowe said last week.
Yet Karen Sanders, the former Mission nurse now working as a patient advocate, said conditions at Mission are prompting high turnover rates. “I have colleagues that are leaving there every day,” she said.
Mission has tried to bridge the nursing gap using traveling nurses, who are often contracted for approximately 13 weeks. Staff nurses say that once many “travelers” experience working conditions in the hospital, they do not return.
Nursing leadership has also been affected, health care professionals said. Six of the 11 directors of nursing, who oversee three to five nursing units each, resigned recently. They include the director of the behavioral health unit of the emergency department, which has suffered a broad depletion of staffing and some violent incidents.
“Too many patients and not enough nurses is the most frightening thing for a nurse, and that is the thing I hear over and over again,” Sanders said. “Do I want to go there if I am sick? No.”
Nurses break down sobbing
On one unit at Mission Hospital, with several dozen beds, nurses are assigned six or seven patients each — double their normal workload — and provided a single CNA, where protocols call for four. “It’s just not safe. It’s led to an increase in falls, and I believe people are getting sicker,” said a nurse in the unit.
“Patients are lying in their own feces for up to an hour,” she said, “and they are not getting their meds for hours.”
Patients can see how short-staffed the nurses are and “feel guilty calling for help,” she said, while nurses are so frustrated that they are sometimes seen sobbing in the hallways. Yet, despite the strain, she said, “My team is amazing. They’re all trying to make it work. They work so hard.”
The anonymous reports are corroborated by multiple signed postings to the private Facebook group Mission Maladies, which has attracted more than 11,000 followers since it was formed after the HCA takeover.
There has been an exodus of staff in Mission’s 95-bed emergency department, one department nurse said, “and we’ve had no replacements. People with critical issues are left unattended, and we have pressure to move patients out as quickly as possible.”
She said this included inappropriately discharging and moving patients to other units “in order to improve ED metrics.”
In addition, the nurse said, “Security cuts have resulted in assaults on staff and attacks on other patients.” One recent incident involved an assault on an experienced ED technician when a patient broke into the nurses’ station from the locked behavioral health unit. “There were only two RNs, one other tech and a clinician present — no security,” the nurse recounted.
The injured ED technician confirmed the account to Asheville Watchdog.
In another incident, the nurse said, “A tech was beaten after escorting a patient to the restroom. She was left unconscious, sustained a broken jaw and was unable to return to work for many months.”
Because of housekeeping cuts, “There’s urine on the floor. There’s no cleanliness to the environment,” the ED nurse said.
“Can we promote excellence of care? No. And it’s all tied up with staffing,” the ED nurse said. “People think that it’s because of the pandemic, and that’s not it. Our community is suffering at the hands of HCA.”
Security guards move corpses
On another floor, a long-time intensive care unit nurse in an area not treating COVID-19 patients said that before HCA took over, an ICU team’s staffing ratio was two patients to one nurse, plus a CNA and a health unit clerk. Now, she said, ICU nurses must attend three patients without a CNA or a health unit clerk.
If a patient dies in the ICU, nurses now have to call security guards to move the body to the morgue, because the unit that normally handles this work, the Office of Decedent Affairs, has been cut back by HCA, the nurse said. Yet security guards are not supposed to touch the body, so nurses have to lift the corpse onto a gurney.
“Now, it’s get them out, move them, move them,” the ICU nurse said. Following HCA’s takeover, she said, “It went to hell in a handbasket in a year.”
Lindell declined to comment on staffing, but said, “Mission Hospital still operates the Office of Decedent Affairs as a community service at no cost to Buncombe County.”
‘Downward spiraling care’
Hospice care has also deteriorated under HCA, according to Tina Puppe, a hospice nurse for more than 15 years. She resigned last year from Care Partners Hospice, which is owned by HCA Mission Health, and in an “exit statement” to her management wrote “we are no longer able to provide quality care, no longer able to provide safe care for our patients and their loved ones despite all our efforts.”
She said the two main reasons for the decline were staffing cuts and the introduction of three new electronic records systems. “Both have essentially created a vicious cycle of downward spiraling care, demoralized staff and patient and family dissatisfaction,” Puppe wrote.
The new systems, she wrote, “only exacerbated all the problems caused by staffing cuts” and are “currently the biggest threats to patient safety.”
“All three systems are dysfunctional and ineffective,” she said. Each of the systems is related to medications, and each was listing different versions of the medications. “They are supposed to communicate with each other, but they do not do that in a reliable way,” Puppe said.
In her statement last year, Puppe said, “There is most likely not one patient that has three correct and congruent medication lists. The consequences can be potentially catastrophic.”
Lindell said, “Our hospice providers are a valuable part of the Mission Health team,” but did not respond to questions about staffing or records systems.
No quality-of-care commitments
North Carolina Attorney General Josh Stein approved the 2019 purchase agreement between for-profit HCA and nonprofit Mission Health but ordered HCA to adhere to 15 commitments — none of them specifically about quality of patient care.
“We sometimes hear concerns about quality, safety and staffing” at HCA’s Mission hospitals and clinics, said Ronald Winters, principal of Gibbins Advisors, the firm hired to monitor HCA’s compliance with the purchase agreement. “Certainly, meeting standards in those areas can have an impact on HCA’s ability to provide required health care services, but many of those concerns also may fall outside of the 15 commitments.”
Winters recommended instead that community members with quality-of-care or safety complaints contact regulatory and oversight entities.
The N.C. Department of Health and Human Services, the state’s hospital regulator, receives care and safety complaints through its Division of Health Service Regulation, but Catie Armstrong of the DHHS Office of Communications said that complaints are confidential and declined to specify how many have been made since HCA’s purchase of the hospital in 2019.
Armstrong said the federal Centers for Medicare & Medicaid Services assesses complaints about hospitals and instructs DHSR to conduct investigations. If an investigation finds that regulations for patient care and safety were violated, the hospital can provide a corrective action plan, which CMS can accept or reject. If the plan is not accepted, the ultimate CMS reprimand is to cut off its contract for Medicare and Medicaid payment.
Six months ago, Mission Hospital’s contract with CMS was under threat after a CMS investigation in July 2020 found three instances of noncompliance with federal standards. In one case, a patient fell off a table and was injured because the hospital “failed to provide care in a safe setting.” In another, the hospital “failed to monitor the condition of a patient” in restraints for violent behavior. And in a third, the emergency department failed to accurately assess a patient’s suicide risk.
Mission kept its contract after submitting a plan to correct the issues, and the plan was accepted, saving the hospital’s Medicare and Medicaid contracts.
More recently, DHHS completed a complaint investigation of sexual misconduct in the behavioral health unit, again citing a failure to provide care in a safe setting.
In February, according to DHHS documentation, video monitoring caught a male patient inappropriately touching a mentally challenged female patient in a dayroom. Security staff was called in from another area of the emergency department to separate them. The hospital’s follow-up step was to separate male and female behavioral health patients in different rooms, but that practice has not been followed consistently, an ED technician told the Asheville Watchdog.
Given her knowledge of hospital protocols, Janet Moore filed a complaint with DHHS in November about her care. Moore said that the regulator investigated her complaint but found her claims to be “unsubstantiated.”
“Although your allegations may not have been substantiated, it does not mean that they may not have had some validity,” the DHHS report read. “At times, it is extremely difficult for us to substantiate allegations unless we are witnesses to what has been charged or there is corresponding documentation in the records.”
Moore has now had a flareup of her previous infection and is currently on intravenous antibiotics for six to eight weeks, to be followed by four to six months on oral antibiotics, she said.
Winters, the independent monitor, also suggested filing complaints with The Joint Commission, previously known as the Joint Commission on Accreditation of Hospitals.
Concerns can also be relayed to North Carolina’s Office of the Attorney General, which has received complaints about the quality of care at Mission since the purchase, said office spokesperson Laura Brewer. However, she declined to specify how many. She said Mission Hospital complaints are passed to DHHS.
Brevard Council asks for investigation
The AG’s office was asked in March by the Brevard City Council to review the departure of 14 doctors from the local Transylvania Regional Hospital, also owned by HCA’s Mission Health. Maureen Copelof, a member of the Brevard City Council who is the city’s liaison to the independent monitor, asked specifically that the AG examine the impact on rural health care in Western North Carolina due to the change from Mission’s nonprofit status to HCA’s for-profit business model. That March 15 council resolution was unanimous.
In a letter to Brevard mayor Jimmy Harris, Stein responded on May 7, saying, “We are closely monitoring the concerns about changes to the quality of care and charity care at HCA Healthcare facilities in western North Carolina, including reports of physicians leaving HCA due to contract concerns.” Stein said that his office would raise the issues with HCA and the independent monitor and pledged, “We will look to do everything in our power to protect health care in western North Carolina.”
Dogwood Health Trust, created with the proceeds from the $1.5 billion sale of the Mission system to HCA, is responsible for enforcing HCA’s compliance with the terms of the sale contract. Erica Allison, spokesperson for the Dogwood Trust, affirmed that quality of care falls outside the 15 commitments.
“Quality of care for all hospitals is regulated by several other bodies, including The Joint Commission and the NC Division of Health Service Regulation,” Allison said, explaining why it did not figure in the 15 commitments.
But, Allison said, “Even though the 15 commitments may not cover quality of care, we understand that specific issues and concerns might be raised that may factor into the independent monitor’s review and evaluation. If that is the case, those issues will be part of the report the independent monitor provides to Dogwood.”
In a chat room of the Osher Lifelong Learning Institute at UNC Asheville, members were told “Now is the opportunity for citizen input into the service quality issues at Mission Health/HCA. So many OLLI members have complained about the quality of care at HCA. Telling your stories to Gibbons Advisors might make a difference.”
Karen Sanders, the RN patient advocate, said, “You have to write complaints. It’s never going to change unless that happens.”
A version of this story abridged for reasons of space appeared in the May 26 print issue of Xpress.
Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Barbara Durr is a former correspondent for The Financial Times of London. Contact her at firstname.lastname@example.org.