A coalition of prominent physicians and patient advocates has criticized the thoroughness of Mission Hospital’s federally approved plan to fix numerous failures documented in a U.S. Centers for Medicare & Medicaid Services report and are demanding to know why the plan doesn’t mandate the hiring of more staff.
Seven doctors and three patient advocates have written a letter to Mark Benton, chief deputy secretary for health at the North Carolina Department of Health and Human Services (NCDHHS), calling the plan to undo Mission’s immediate jeopardy status and a host of associated deficiencies “insufficient.”
The letter sharply criticizes the plan because it doesn’t require Mission to hire additional and more experienced staff, something nurses have been advocating for in the years since HCA Healthcare purchased the hospital system in 2019. It also raises concerns about Mission’s ongoing compliance and its withholding of documents that investigators had sought. It also proposes a third-party monitor for the plan of correction.
“In short, HCA’s response offers only bureaucratic solutions to what is fundamentally a workforce issue,” the letter states.
“[W]e believe that the (plan of correction) is insufficient to address the shortcomings evidenced by the Immediate Jeopardy findings,” the letter also states, contending that if the plan were implemented as approved, patients would remain at risk.
“I received this memo yesterday, February 20, 2024 – the same day state and federal surveyors returned to HCA-Mission,” Benton told The Watchdog. “I shared it with my regulatory team who, like me, appreciated the recommendations from physicians and other concerned stakeholders on Mission’s plan of correction.”
HCA and Mission spokesperson Nancy Lindell told The Watchdog that Mission began making changes in December based on the investigators’ preliminary findings, adding that “these findings are not the standard of care we expect, nor that our patients deserve.”
“We are pleased that CMS has accepted our Plan of Correction, ” Lindell said. “We are pleased to hear from our EMS partners and patients that those actions are yielding positive results, including decreased wait times for care.”
The group shared the letter with the media Wednesday. Its members include doctors Clay Ballantine; Brian England; Scott Joslin, a former lead hospitalist at Mission; Bruce Kelly; Robert Kline, a former Mission board member before its sale; former emergency department doctor Allen Lalor; and Mike Messino, founder of Messino Cancer Centers.
The doctors and more than 130 others signed a letter in October decrying HCA for “gutting” community healthcare in western North Carolina because of its profit-centered management.
The coalition also includes local pastor and former Mission chaplain Missy Harris, Victoria Hicks of the Health Equity Coalition, RN patient advocate Karen Sanders, and Miriam Schwarz, former executive director of the Western Carolina Medical Society.
The coalition will hold a news conference about its concerns outlined in the letter at 10 a.m. Thursday at the Buncombe County government building.
A 384-page CMS document obtained by Asheville Watchdog last week chronicled an array of failures in Mission leadership and procedures that had contributed to the deaths of four patients and injured others. It detailed why the agency placed Mission in immediate jeopardy, the most serious sanction that can be levied against a hospital.
The long-awaited report also included Mission’s plan to correct the conditions that led to those incidents, mostly by improving policies and educating staff. CMS required HCA and the hospital to present the plan by Feb. 6 or face the loss of its Medicare and Medicaid funding, which would threaten the facility’s financial viability. CMS requires Mission remove the conditions that caused the immediate jeopardy by Feb. 24.
The plan of correction contains barely a mention of increased staffing as a solution for deficiencies. Instead, it notes the use of staff memos, process reviews, reassessments, and audits.
“These solutions are also more focused on individuals being the problem rather than the systemic lack of staff and resources,” states the coalition’s letter, noting that while these improvements might be warranted, they don’t address the larger issue of inadequate staffing.
An internal document obtained by The Watchdog on Tuesday — as NCDHHS investigators returned to Mission to monitor the hospital’s compliance with its plan of correction — showed how the plan was being implemented in the emergency department. Mission now has a goal for patients to be seen, triaged, and assigned to a nurse within 10 minutes of arrival, according to the document. Another goal states that lab results should be returned 30 minutes after they are ordered.
Extremely long emergency department waits and lab test delays were contributing factors in the deaths and injuries of patients chronicled in the CMS report.
“The POC does not address what we believe to be the primary driver in each of the Immediate Jeopardy situations (and many of the other cases discussed in the CMS report): the lack of adequate, experienced staffing,” the coalition’s letter states. “Medical providers, patients, and others have repeatedly decried the lack of staff, and nurses have repeatedly filed Objection to Staffing forms. CMS’s findings of Immediate Jeopardy confirm that lack of staffing is key, and that the standard for adequate staffing laid out in 42 CFR 482.23(b) is not being met.”
The letter requests Benton consider staffing data; ask if HCA closes emergency room beds when staffing is low; find out if HCA keeps patient-to-nurse ratio data; find out if there is consistency in how many nurses call out in a given shift; and read the many objection forms nurses have filled out when they don’t feel they can provide care safely.
“A question for you is, if HCA is deemed to be in compliance with the POC later this month, what is your recourse if the approved plan proves to be inadequate over time?” the letter states. “Can you require a revised plan with more specific requirements for staffing levels and experience?”
Each of the doctors who sent the letter worked at Mission in some capacity — including leadership roles — and told Benton they had first-hand knowledge of why the system was broken.
“We know that the primary problem is inadequate staffing and experience. No level of improved process, education, huddles, or documentation will change that,” the letter states. “We again strongly urge you to keep this in mind as you perform your inspections. We further urge you to hold HCA, to the degree you are able as part of the monitoring process, to hiring, placement, and patient ratio standards that are necessary to correct the Immediate Jeopardy instances on a permanent basis.”
Sanders, the coalition member who is an RN patient advocate, said she thought the plan of correction was missing several important elements including improvements to reporting processes and especially lax staffing standards.
“I am disturbed because in HCA’s presentation of all of their actions, there’s nothing in there about improving the nurse to patient ratio,” Sanders, who holds a master’s degree in nursing and formerly worked at Mission Hospital for 16 years, told The Watchdog. “But the problem is they don’t have enough nurses. So a lot of things fell through the cracks.”
She said she’s happy to be part of a coalition pushing for more regulation but said there needs to be even broader community support for change. To that end, she is establishing a retired nurse corps to advocate for patients, nurses, and better health care.
The letter also requests:
- That there be frequent, unannounced inspections and detailed monitoring during the time provided in the plan of correction and that the monitoring period be extended, if at all possible.
- That NCDHHS interview Mission staff who were listed as “not available” in the report and that any documents withheld from investigators be turned over to the agency for review and further recommendations.
- That all future investigations require complete transparency in documenting evidence.
- That an unaffiliated, non-conflicted third party well-versed in hospital systems be assigned by CMS to closely monitor HCA’s execution of the plan of correction.
Nurses have called for more staffing for years
For years, the Mission nurses union has maintained lack of resources and staffing have endangered patients and put employees at risk.
Even new nurses working full time at the hospital feel the pressure of understaffing, which they say is especially obvious as Mission tries to repair deficiencies with more processes and education.
“It’s 100 percent a staffing issue,” said Tucker Richards, an emergency department registered nurse and union member who said he has been working at Mission for about a year. “This is at its very core a staffing issue, and it always has been, and that’s the whole reason why NCDHHS had to show up.”
Richards and other nurses who have spoken to The Watchdog agree that the finding of immediate jeopardy was caused by lack of staff.
“There’s not a single nurse in this ER who is not coming into work every day and giving 1,001 percent,” Richards said. “We all really show up and work our butts off and go home and just try to feel okay about coming back to work and doing it again the next day. There’s no amount of additional education … that they can ask us to do that will improve these metrics or whatever they’re talking about.”
[This story has been updated to include responses from Mark Benton, chief deputy secretary for health at NCDHHS; Nancy Lindell, HCA and Mission spokesperson; and RN patient advocate Karen Sanders, a member of the coalition.]
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.
Good on these people for seeing through the BS plan of correction. NCDHHS has never before dealt with the likes of HCA and clearly doesn’t grasp who they are up against. The system itself seems counter intuitive, for HCA to come up with their own plan of correction, when they were the ones to implode our healthcare system in the first place. Shouldn’t someone else be demanding the terms to fix it? It seems HCA still holds all the power to do whatever they want while patients pay the price with their lives.
Having been to HCA (my memories of Mr. Burgin’s Mission St. Joseph’s are to precious to call the current fiasco Mission) twice in less than 3 months to say the ER was a debacle is being kind. I will not go into detail as they are similar to the many that were previously cited (long delays, missed meds, no monitoring). I will point out those were errors rooted in staffing shortages, not due to improperly trained professionals.
Healthcare by the bottom line is an egregious mistake with fatal consequences to the families of western North Carolina. MSJ was the hospital I worked for, (25 years) respected and wanted my loved ones and neighbors to go to for what was then excellent care. Not anymore.
It is time that this disgusting situation be put in the National spotlight via a partnership with “Asheville Watchdog’s” excellent reporting and say 60 Minutes. This will alert other hospitals to the disaster that is HCA’s healthcare by the bottom line.
Please contact the. Joint Commission which is charged with accrediting Mission , what they are planning to do about the CMS report and patient safety concerns….Having a watchdog report about this might trigger some action from them
I have contacted JACHO x2 re: Mission. You do not get a response back from JACHO so who knows where your concerns go.
RN for 53 yrs, and recent pt x 2 in ER n admit, i have nurses perspective as to the Hell hole that is now HCA. Please contact me
Please consider sharing publicly. Seems to me the time of secrecy is well past. Healthcare situation in this community too dire.
This is not at all surprising that HCA submitted a POC without increased staffing but it is outrageous that such a deficient POC was accepted.
Can’t help but think NCDHHS dropped the ball again. First by not showing up for two years to investigate after the nurses told them how bad it was, now this.
All options should be on the table, people have died and this is the best we can do? More will die.
It’s from lack of staffing at NCDHHS. It’s been that way since covid.
Yes, the reporting appears to need to be at the level of who is letting HCA get away with creating its own remedy on paper when the remedy is staffing which means they fork out money.
Thank you for all that AVLWatchdog is doing on this story. The fact that we have a deplorable hospital should strike fear in the community. We will all have to go there, at one time or another, and their ownership’s lack of consideration for the patients is outrageous.
100% staffing issue is exactly right! How can HCA think that saying things in the ER need to be done within 10 minutes will fix anything? Do they really think that staff would not do that already if there was actually enough manpower to get things done any faster? Gee whiz. How can we get out of this HCA disaster? HELP US, some non-for-profit hospital chain!
Unfortunately, the so-called “non-profit” and/or 501c3 Hospital Systems are often as bad — sometimes much worse! — than the for-profit ones, especially in terms of exorbitant costs for services and procedures, coupled with low or insufficient staffing. The fact is, they are also about profit, at the expense of quality healthcare for patients. They just hide this fact behind the smoke-and-mirrors of calling themselves (for example) a “Catholic charity hospital.” Please Google Mr. Ernie Sadau, the CEO of CHRISTUS Health System, a chain of hospitals and satellite medical services with headquarters in Houston, Texas. This so-called non-profit healthcare system pays Ernie Sadau $13,500,000.00 a year (yes, that decimal is in the right place), plus another 6.8 million in “additional forms of annual compensation.” Several others in the “executive suite” also make multi-millions a year. They charge sky-high prices for all of their so-called healthcare services — and the services are so sub-par that their Santa Fe, NM hospital, CHRISTUS St. Vincent’s, has the well-earned nickname of “St. Victims.” It is well past the time for the IRS to be investigating/going after these fraudulent enterprises, flying under the radar with their myriad of 501c3 tax-breaks.
The fact is, healthcare systems throughout the entire United States are FUBAR, and a complete overhaul is needed both locally and nationally. Vulture capitalism and for-profit medical care should be abolished. Canada and the UK did it — why can’t we?
Certainly makes sense, as the same problems will be there if there is insufficient staff to implement the changes.
It is clear from your previous reports on Mission/HCA’s conduct and policies that sufficient staffing is the key to improving patient care. I’ve been in the hospital frequently with family who’ve needed various surgeries, procedures and ER visits since HCA’s takeover. Some of the units look deserted, the staffing is so limited. The waiting time is dangerous. Expecting nurses to triage patients quickly and provide lab tests in a timely manner is only possible if there is adequate staffing to do the jobs. This is common sense.
Labs aren’t done by the nurses but I expect the lab is short staffed as well. There is no way a single lab technician can cross match blood. do stay chemistries and a CBC in 30 minutes.
This is absolutely a staffing issue. When I worked for a hospital in Atlanta that was bought by HCA, I was the OR supervisor. HCA refused to hire enough staff to adequately staff the ORs. When I pleaded with the administrator for this to be rectified, his answer was “that’s your problem. We are not hiring more staff.” This was 30 years ago & nothing has changed It’s all about profit over patients and the ability for staff to deliver safe care!
I agree with Drs and nurses that decreasing amount of time in ER does not solve problem of not having enough staff to accommodate the changes. No amount of diagnostics and data review take place of all hands on deck!
Perhaps a followup story idea would be how Advent Health Emergency Department numbers and general care figures reflect compared to the HCA/Mission numbers since 2019.
In April 2023 I was on chemo and spiked a 103 temperature. My physician called Mission ED (6 plus hours wait) and Advent (15 min). So we drove the extra miles and were promptly waited on. They did a lot of tests and a CT. Got my temp down to 100 but unfortunately they did not have any Oncology services. I was transferred by EMS to Mission and waited two hours to be seen and 14 hours to get a room on the Oncology floor. The ED was chaotic due to staffing levels.
FYI – Pardee has oncology services. Good to know. Check out their website for more info.
Profits before patients is certainly an important element of this problem that we can hope to correct locally by making a LOT of noise. I doubt they’ve previously encountered a population like Asheville’s in that regard. But I worry about a more generalized problem: that we are not training enough doctors, nurses, and paraprofessionals to meet the needs of our aging population. That and the COVID pandemic have made it very tempting for practitioners to go where the money is, or find another career, or retire early. Burnout became a BIG problem during COVID, btw. Good luck managing this problem! Shame it has to be so massive.
a “patient” could go to the ER, sign a Release of Information document, and a video could perhaps be made scooting past all the HIPAA BS.
It is upsetting that the investigations by the DHHS were done and completed in less than 15 days. My complaint did not involve death but was life-changing to me because of bad care and poor choices by those who are most important during any surgery. I would not have ever wanted to take away time to those whose care resulted in death but I don’t feel the investigation done was long enough to investigate claims against staff. These should have been conducted by investigations of all witnesses and paperwork. I don’t care for a claim to come back unsubstantiated after only having interviews and those saying it never happened. I will move forward not without having fears of going in for surgery again. I wish they would sell out to a non-profit and leave Asheville.
john bowel
Why is my Dominion Energy natural Gas bill so high when natural is so plentiful
an sells for about $2,30 per unit.
who is getting all the money???
Nurses and doctors should quit and leave HCA in more of a lurch. This isn’t the only hospital to work for. Go find a better position at a regional hospital or surgery center that cares about its patients and medical personnel. If your primary care doctor only has privileges at Mission, get a new doctor who can treat you at another hospital in the area. It seems apparent that HCA has the NC state board in its pocket with this ridiculously quick approval to HCA’s promise to do better. Nothing will be done to rectify the real problem now. How many more will have to die?
Since a new contractor [ Independant monitor] will be responsible for reviewing HCA Healthcare’s compliance with the 2019 agreement to buy the Mission Health system doesn’t it make sense that a local organization should be assigned the job? How can an out-of-state company keep a close eye on the operation.
There are plenty of retired executives and active and retired members in the medical profession who could form the organization. Perhaps with Buncombe County Commissioners’ oversite.
Maybe some of the local HCA critics should “walk the walk”.