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 Tuesday by Asheville Watchdog.
North Carolina Department of Health and Human Services (NCDHHS) investigators visited HCA Healthcare-owned Mission on Tuesday, 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.
“DHSR (Division of Health Service Regulation) staff are currently on-site conducting a follow up survey,” NCDHHS spokesperson Hannah Jones said Tuesday. “DHSR cannot comment on ongoing investigations.”
Mission and HCA spokesperson Nancy Lindell did not specifically respond to The Watchdog’s questions about the changes in procedures, the visit, or what will happen next but issued a statement that said, “We are pleased that CMS accepted our Plan of Correction and we will continue to collaborate with the surveyors through this process.”
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 Thursday. That report described long waits in the emergency department, significant delays in lab work, and neglect that contributed to the deaths of four patients and injury to others.
The internal document obtained Tuesday 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 Feb. 24 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.
Curious.
Does that also include more personnel to handle the more stringent requirements, or is that going to stress staff even more?
My question would be, do they enough staff right now to implement these procedures?
I see nothing here about HCA committing to adequate and appropriate staffing in ALL departments. It seems they are trying to make already overworked staff do even more without providing the staffing or the resources necessary to meet these goals.
An extremely sad situation we are in.
HCA can buff up their front line policies and procedures all they want, but if additional, properly trained and experienced staff are not provided, in the right places and at the right time, nothing is going to change. Surely DHHS and CMS are not going to fall for this BS!
Of course… the main problem is nurses having a water bottle or a cracker at the nurses station. The management and inspectors really need to make sure to get that cleaned up.
Just that small thing is infuriating to anyone who is trying to survive in the reality of nursing today.
How can nurses shine when their job (HCA) requires them to already be on fire? (Attempting to do more work than is humanly possible).
Did I miss something? Where is the part about holding management responsible for staffing in numbers and appropriate training to safely meet these targets? And what about people admitted to rooms begging for baths, filthy rooms, not even basics? If this gets these vultures off the hooks, and this is all, then unacceptable. Looking forward to more from AVLWatchdog on HCA’s plan, and what was accepted by regulators. Will they hold management accountable, and monitor them, for chronic by design skeleton staffing.
The corrective action steps sound great. However, will allow adequate staffing levels?
During my 10 1/2 hr. wait in the e.r. NO ONE attended to me-I was one of HUNDREDS of people waiting-it was like what I imagine a 3rd world country would have. I even had papers from my doctor which I had just come from-stating what the problem was and the steps needed to care for my situation. Nurses were not interested in even looking at them. I agree-the money hungry ghouls who run the hospital will resume old ways once the ‘crisis’ passes. I most definitely have PTSD from my excruciating experience and NEVER want to go there again.
Ethel, your experience is so similar to mine. I was traumatized as well.
I sincerely hope that somehow HCA and Mission turn around, but sadly I think this is temporary .
My experience was quite similar. I’m moving.
Thanks for all your working investigating and reporting this critical information.
What is HCA doing to hire and retain sufficient ER staff including RNs, phlebotomists, MDs, lab technicians and CNAs for 24/7 coverage?
Yes, Hire People who actually gives A Dam about People.
This nurse and others know…exactly what will happen. Nothing will change after surveyors are gone.
“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.”
Have to go for back surgery next month, AND I am scared to death of the hospital…. not the procedure!
I understand that. I would advise that you have a trusted person stay with you round the clock during your stay.
NCDDHS and CMS, please protect the staff and patients and plan your unannounced follow-up visits. This RN’s quote from the article captures what many feel “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.”
My recent experiences in the ED found competent and caring staff, but no where near enough staff to meet the demand. I hope the investigators are monitoring the demands of patient load.
New policies do not become hardwired until they are translated into processes. Once processes are developed, education, validation followed by re-education and ongoing validation for several months! Only after months of consist, hard work by every employee will these new policies perhaps be fully realized!
I’ve worked in dozens of ER’s—massive hospitals, small hospitals. Ten minutes is an impossible schedule. That’s not happening anywhere. Where did this 10 min come from? Yes, you see people immediately coming in with chest pain. Yes, you see people immediately who are in cardiac arrest.
I say we go down to the ER, take out our phones, and time them. Utterly ridiculous. Who made up this 10 min?
Cool idea there, Ms. Hammond. Imagine a website ER patients could access where one could enter text/video to document their Mission ER experience.
So more pressure on the existing nursing staff but no additional staff? How can this be sustainable when understaffing is one of the main problems that caused the poor level of care?
Yes, I was wondering the same thing. But if they do increase staffing, is it possible to have a mechanism in place that would monitor staffing levels and trigger some kind of response by the state were they to drop to unsafe levels. Clearly, HCA needs near constant oversight or staffing will drop. If HCA can under the cover of darkness, they will. Asheville Watchdog, could you keep this in mind in your reporting. I’m sure the nurses would be a good source of information as to what is going on in the Emergency Room. Thank you again Asheville Watchdog for reporting on this as if your life depended on it, because in truth someone’s does.
I agree that HCA must adhere to adequate staffing levels, but it is not journalists’ responsibility or area of expertise to monitor that. Where in this plan is a commitment to specific staffing levels? How would said levels be enforced? Only with an outside agency doing frequent unannounced spot checks (with dire consequences for HCA) would there be any chance of actual improvement. I am not hopeful.
If one drills down, one finds that NOTHING has changed. HCA Healthcare remains a for-profit business with value to shareholders, their primary customers, before all else.
Exactly, it’s All about the Money.
when a hospital is this far gone, it takes an outside neutral consulting firm to come in, clean house and right the ship. To expect HCA to honestly critique, admit to and correct the problems they created on purpose to reap billions is ludicrous. The ER is a death trap but so is the entire hospital. We are supposed to believe they can fix this dumpster fire in a matter of weeks with their little typo ridden check lists? And going back and changing records from weeks prior? Wow. Just wow.
Mission Hospital is a Joke. No Compassion for people, my Daughter was sent to Mission from an Urgent care because her Blood Pressure was so High.After over 12hrs of sitting in the waiting room, with a nurse who came by every now and then to check her blood pressure, she finally got called to a room, where she sat for over an hour, before a so called Dr.came in, checked her and sent her home with a Prescription that she couldn’t get filled toll the following day. Mission and All the Hoespitals are making Millions, alone with the Pharmaceutical Companies who dish out Medication like its candy, if it don’t Cure you, it will Kill You.
Jan 11, 2023 Health Tech, Hospitals Reported by Katie Adams: “About 300 employees will rally at HCA’s hospital in West Hills, California to call attention to the dire staffing levels at the health system’s more than 150 hospitals in 19 states.” Mendez, an executive director of Local 121RN stated, “it’s not a lack of ability—-it’s an absolute lack of will.” “HCA has the ability to pay workers, retain and recruit.” But instead HCA handed out $8 billion in stock buybacks in 2021.
We are seeing in numerous reports in numerous cities, the same life threatening, dire working conditions at their hospitals. It’s clear where their priority is…meeting the next corporate earning goals and avoiding the glaring inadequate staff challenges.
We look forward to and encourage NCDHHS continued and vigilant inspections to ensure there are no more deaths due to unwarranted health standards.
Google HCA and you can spend hours reading articles on their prior penalties, country wide nursing/staffing shortages and what can be called nothing other than their lack of respect for their staff and patient care.