As state inspects Mission for CMS, hospital makes changes to emergency department

Mission Hospital has halted some patient transfers to its often-crowded emergency department and has tried to add more physician shifts while the North Carolina Department of Health and Human Services conducts inspections at Asheville’s HCA-owned hospital, Asheville Watchdog has learned.

State inspectors have been at Mission since early November, investigating complaints about its emergency room staffing, policies, and procedures on behalf of the federal Centers for Medicare & Medicaid Services. The Watchdog first reported the inspections on Nov. 14.

About a dozen investigators have been interviewing hospital physicians, nurses, and staff, reviewing hospital communications, patient records, and other documents, and analyzing systemic safety procedures to ensure minimum standards of care, according to multiple sources, some who requested anonymity because they were not authorized to speak to the news media.

“The work the [North Carolina Department of Health and Human Services] team is undertaking at HCA–Mission is being done on behalf of the U.S. Centers for Medicare & Medicaid Services (CMS),” NCDHHS Chief Deputy Secretary for Health Mark Benton said to Sen. Julie Mayfield, D-Buncombe in an email obtained by The Watchdog.

A CMS spokesperson said in a statement Wednesday that it was committed to holding facilities accountable for meeting certain health and safety quality standards.

“CMS has communicated with NCDHHS about its delays and are providing technical assistance and collaboration for NC State to overcome obstacles that may cause delays in CMS’s complaint investigations within the levers CMS has available to do so,” the spokesperson said.

CMS refrains from providing details of any potential or pending action to protect the integrity of an investigation, the spokesperson said.

The Joint Commision — an independent, not-for-profit national organization that sets standards for safety in health care — has been sending inspectors to Mission since at least September, according to a nurse who said she was interviewed by a Joint Commission representative at the end of that month.

Mission did not respond to several questions about why it had offered more physician shifts or halted some emergency department transfers from other regional hospitals while the inspectors are on site in Asheville.

Questions about handoff procedures

The inspections are happening as North Carolina Attorney General Josh Stein’s office also is investigating Mission, requesting 41 sets of documents about its oncology and emergency services and saying the HCA Healthcare has violated part of a 15-agreement commitment it made when it bought the Mission Health system for $1.5 billion in 2019. Stein is running for governor as a Democrat.

Accreditation and certification from The Joint Commission is highly coveted by hospitals. According to TJC’s website: “During the survey, surveyors select patients randomly and use their medical records as a roadmap to evaluate standards compliance. As surveyors trace a patient’s experience in a healthcare organization, they talk to the doctors, nurses, and other staff who interacted with the patient. Surveyors also observe doctors and nurses providing care, and often speak to the patients themselves. All regular Joint Commission accreditation surveys are unannounced.”

Claire Siegel, who left her job as a Mission surgical unit nurse this month, told The Watchdog she was interviewed late September for two hours by a TJC surveyor, who questioned her about handoff procedures in the emergency department. Siegel was a member of the Professional Practice Committee (PPC), a group of unionized nurses at Mission designated to raise nursing concerns with hospital leadership. 

TJC declined The Watchdog’s request for comment about its inspections.

The Watchdog has learned that Mission stopped accepting transfers of some patients from other hospitals’ emergency rooms, which will decrease the number of patients in an emergency department nurses have said is constantly overburdened.

Depending on availability of beds and staff, Mission Hospital can either be open for transfers or closed for transfers from its regional hospitals. Regardless, Mission always accepts trauma, stroke, and heart attack patients.

Even when it is closed, Mission’s emergency department also normally accepts patients who have other very serious conditions, some life-threatening and many time-sensitive — it can only do so after an employee consults with the administrator on call. But the process for accepting such patients changed Monday.

Under the new policy, these patients are no longer being accepted at all during closure, meaning regional hospitals will have to send them elsewhere. Halting these transfers means the emergency room may be less crowded for as long as the policy is in place.

Mission did not respond to questions about why it decided to stop this process or when it would reopen such transfers, if at all.

Mission is also offering more shifts for emergency room physicians, according to an email obtained by The Watchdog sent Nov. 14 by Matthew Riester, an emergency medicine doctor employed by TeamHealth, a company that contracts with Mission to staff its emergency departments with doctors.

“We have been able to add coverage for IPA from 2p-10p for BONUS shifts,” Riester said. “Open on shiftadmin now. GET THEM WHILE THEY LAST!”

IPA stands for internal process area, a place in Mission’s emergency department where patients wait and receive visits from emergency room physicians. 

Riester also noted in his email TJC’s presence at the hospital.

“Please be courteous and willing to answer their questions as needed,” Riester said. “If you have any questions please (let) any of the leadership team know.”

The Watchdog emailed Riester for comment. Instead, a TeamHealth spokesperson responded and asked for more information about The Watchdog’s reporting. But the spokesperson did not respond to several questions about staffing in the emergency department.

Minutes from a service line meeting of physicians held Nov. 15 also noted TJC’s visit and said the organization was “pulling 75 charts going back to 2021. They are asking to speak to the physicians and (advanced practice clinical staff members) that are involved in the case.”

Charts are patients’ electronic medical records.

The meeting notes specifically pointed out that this visit by the TJC was “a little different than prior TJC surveys.”

TJC asked Mission employees what they do when there are no patients in the internal processing area and what the hospital does when “all the beds are full and how we move sick patients out of the waiting room.”

TJC also asked about emergency department staffing, according to the notes, including the maximum and minimum numbers of physicians and advanced practice clinical staff members working at any given time.

“Everything looks a lot prettier for the surveyors”

Nurses have raised concerns since HCA Healthcare bought the Mission Health system that the Nashville-based company doesn’t do enough to make sure departments are fully staffed. They have filed numerous complaints since at least 2022 saying that the hospital refuses to staff departments as needed, leading to uneven nurse-to-patient ratios and ultimately putting patients in danger.

Some nurses who work in the emergency department said they have observed significant changes after surveyors and inspectors showed up.

“(Nurses) were being told that they could pick up any day that they wanted for any amount of time, and that’s not usually the case,” said Hannah Drummond, an emergency department  nurse and a National Nurses United union member, discussing those changes. “So staffing has been glorious. Our flow and the department has been glorious. Patients are getting bedded a lot more appropriately.”

Drummond said no one in administration has told nurses why there has been such an abrupt change in operations while state and TJC inspectors are visiting Mission.

“Everything looks a lot prettier for the surveyors,” Drummond said. “No one is coming out and saying that from our management, but we know that that’s why it is.”

Drummond said she has been interviewed by NCDHHS inspectors but would not talk about those conversations. She said department officials told her the inquiry was happening on behalf of CMS.

Drummond added that surveyors and inspectors had taken the week off for the Thanksgiving holiday and the quality of staffing suddenly declined again this Monday.

“I’m furious,” Drummond said, discussing what she said was a sharp drop in Mission’s management of the emergency department once inspectors were gone. “This is negligence on the part of management at Hospital Corporation of America. And I emphasize the ‘corporation’ part.”

NCDHHS would not comment on “when our onsite investigation will conclude,” spokesperson Summer Tonizzo said.

[Editor’s note: This story was updated Wednesday afternoon to include comments from CMS.]

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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. To show your support for this vital public service please visit avlwatchdog.org/donate.