Written by Andrew R. Jones and Victoria A. Ifatusin, Asheville Watchdog.
Mission Health facilities in Asheville had more than 450 registered nurse vacancies in mid-October 2023, according to company staffing data obtained by Asheville Watchdog. The deficit occurred during a five-month period marked by 10 instances of federally chronicled patient death and endangerment at Mission Hospital, which had most of the openings.
The vacancies, roughly 27 percent of all registered nurse positions at the time, were part of ongoing staffing deficits between 2022-2023.
During that time, HCA Healthcare-owned facilities — including Mission Hospital, Sweeten Creek Mental Health and Wellness Center, Asheville Surgery Center, and the new urgent care center in south Asheville — lost at least 660 registered nurses and hired more than 1,500 temporary workers to try to fill deficits in its core labor force, according to the data.
Eighteen incidents of patient death and endangerment at Mission Hospital were detailed in a 384-page report in February from the U.S. Centers for Medicare & Medicaid Services, which placed the hospital in immediate jeopardy, the most severe sanction a healthcare facility can face. The incidents occurred between April 5, 2022, and Nov. 28, 2023. Sixteen involved staff shortages, delays in care, or no available rooms.
Ten occurred from June 30, 2023, to Nov. 28, 2023. On Oct. 19, 2023, Mission had 452 non-management registered nurse openings out of more than 1,600 registered nurse positions, according to HCA bargaining unit data and the nurses union. The union represents all bargaining unit nurses.
By Feb. 5, a little more than two months after a state and federal investigation that led to the immediate jeopardy finding, that number had dropped to 302, or nearly 19 percent of the total non-management registered nurse positions at Mission facilities in Asheville at the time.
The national vacancy rate for registered nursing staff at hospitals in 2023 was 9.9 percent, according to the most recent NSI National Health Care Retention & RN Staffing Report. On October 19, 2023, the Mission facilities’ registered nurse vacancy rate stood at nearly 27 percent, according to The Watchdog’s analysis.
In 2022 and 2023, nurses implored hospital leadership to improve working conditions, according to minutes from meetings between nurse union members and management obtained by The Watchdog.
They asked leadership to retain staff and make more permanent hires instead of addressing gaps with short-contract traveling nurses who move from hospital to hospital.
It is unclear whether Mission has a focused plan to increase its workforce and retain full-time and part-time staff in the near future.
The Watchdog asked Mission Health spokesperson Nancy Lindell more than 30 questions about staffing over the past two years, including if a lack of nurses could have contributed to the deficiencies and deaths detailed in the CMS report.
Lindell did not respond directly to most of the questions, instead pointing to a March 12 staffing document Mission provided CMS. The Watchdog had obtained the document earlier through a public records request and sent it to Lindell for comment.
The document, a broad overview of the hospital’s staffing strategy, was replete with inaccuracies and omissions, union nurses said.
“We made positive strides in 2023 to fill open positions, having added almost 200 experienced RNs and 100 new graduate RNs to our staff,” Lindell said. “We continue to heavily recruit and to support the education of future caregivers through our partnerships at area colleges of nursing.”
Less than two weeks after Mission leadership told staff the hospital was facing immediate jeopardy, an HCA executive told a union nurse staffing committee that there was no plan to add staff because of the state and federal findings, according to minutes from meetings between management and the committee obtained by The Watchdog.
“Does the hospital have plans to change staffing because of the health department (investigation)?” Quinn Mullis, an operating room registered nurse and union staffing committee member, asked management during a Feb. 14, 2024, staffing meeting. HCA Labor and Employee Relations Director Scott Rogers shook his head and said, “Not that I know of,” according to the minutes.
Rogers did not respond to The Watchdog’s request for comment.
Staffing shortages, delays in care
The Watchdog examined each of the 18 incidents detailed by CMS. The following are some in which Mission staff, EMS workers and others mentioned staffing issues to investigators:
Delays in care contributed to the death of a 78-year-old woman on April 5, 2022. She arrived at Mission complaining of an abnormal heart rhythm and died less than four hours later, waiting for care in the Red Pod — an emergency department area for the most acutely ill patients. One nurse said staffing in the pod that day was four patients to one nurse. “If a nurse tells me ‘I’m overwhelmed,’ I will ask another nurse to assist with patient care,” the nurse told investigators.
A 66-year-old woman arrived at Mission on July 4, 2022, with abdominal pain, nausea, and vomiting. She had a small bowel obstruction and doctors ordered medication she didn’t get, causing her pain to spike to a 10 on a scale of 10. “At that time there was one nurse in the waiting room to triage patients,” a nurse told investigators. “One hundred percent, patients are not safe, orders are not completed, and staffing is a concern. There is one nurse with a line out the door, I can put orders in, but it is not going to get done because of the volume of patients and minimal staff.”
An investigation into the July 15, 2022, death of a 48-year-old man found that a nurse assigned to him was caring for five patients when his intravenous medication ran dry. There were 295 patients in the emergency department that day, according to a nurse interviewed by investigators. A lack of staff led to deficiencies in care that day, nurses said. Mission’s own investigators disagreed, according to the report.
On March 18, 2023, a patient received an expired dose of chemotherapy. Cancer care staff told investigators “the oncology unit lost valuable nurses which led to the hiring of new/inexperienced staff, and increased use of travel staff. The changes in staff led to an increase in errors, especially with neutropenic patients (patients with a low count of a certain kind of white blood cell), which resulted in a degradation in care.” Investigators also found that “pharmacy errors increased secondary to the loss of experienced oncologist pharmacists.”
On August 14, 2023, a 39-year-old man “was in the waiting room for 9 hours, did not receive any medications for alcohol withdrawal, then had a seizure and sustained a head injury,” according to the CMS report. Mission’s own investigation of the incident found the “primary action to prevent recurrence” was “increase in staffing/decrease in workload,” according to the report.
An EMS worker and a Mission microbiology employee mentioned lack of staff when describing the circumstances that led to a 66-year-old man’s death on Oct. 17, 2023. “Interview (with EMS) revealed waits had gotten more common recently and it seemed like a staffing issue,” an investigator wrote in the report. CMS determined the death constituted an Emergency Medical Treatment & Labor Act (EMTALA) violation, prompting the agency to issue a separate citation to the hospital.
In one incident review, investigators cited Mission’s own policy, which was last revised in 2015, according to the CMS report: “Mission Hospital will maintain staffing to meet patient care needs on all nursing units.”
The cost of turnover
Mission paid for about 1,550 travelers to complete more than 2,680 contracts between July 2, 2022, and April 20, 2024, according to the data obtained by The Watchdog.
Many of these travelers, who often make twice as much hourly as full-time registered nurses, signed on for several contracts ranging from fewer than two weeks to more than seven months. The average contract during this time lasted about three months, which is standard across the U.S.
Travel nurses work in unfamiliar hospitals and communities, forcing them to establish relationships and learn procedures quickly. There is no published evidence showing exactly what effect travel nurses have on patient outcomes.
“Adverse associations between travel nursing and patient care may reflect staffing levels or work environments rather than the specific care by the travel nurses themselves,” a 2023 article in Health Care Management Review concluded.
In mid-September 2023, there were 352 travelers working at Mission as registered nurses. As of Feb. 4, three days after CMS informed Mission and HCA that the hospital had been placed in immediate jeopardy, there were 376.
Mission’s plan of correction to address the deficiencies found by investigators, which was approved by CMS, did not include a significant effort to staff the hospital with more full-time and part-time registered nurses or to wean itself off traveler nurses.
Lindell said Mission was “pleased to have had more than 60 of our travel RNs join our team here at Mission as permanent staff members since 2023.
“Mission Health hospitals also have recently achieved an RN turnover rate at Mission Hospital that is approximately half the national benchmark, with some of our regional hospitals in the single digits.”
The national turnover rate for full-time and part-time registered nurses was 18.2 percent in 2022 and 15 percent in 2023, according to the NSI report.
The average cost of turnover for one bedside registered nurse was $56,300 in 2023, up from $52,350 in 2022, according to the same report.
Lindell did not respond when asked to provide exact turnover rates for each of the six Mission Health hospitals in western North Carolina.
In December, four days after North Carolina Attorney General and Democratic gubernatorial candidate Josh Stein filed a lawsuit against HCA for allegedly violating agreements it made when it purchased Mission for $1.5 billion in 2019, the North Carolina Nurses Association issued a statement about conditions at Mission.
“Staffing levels and standards of care at Mission Health have been an area of concern since the hospital was first sold to HCA Healthcare,” NCNA President Trish Richardson said in the statement. “The North Carolina Nurses Association (NCNA) does not typically comment on the business practices of individual hospitals or health systems, but we made an exception for this specific situation nearly four years ago. Unfortunately, in the years following the purchase of Mission Health, we have seen no evidence of improvement in the level of trust between HCA, its staff, and the community.”
Nurses: Mission has not prioritized staffing
Even though CMS lifted the immediate jeopardy finding after Mission issued its plan of correction in early February, the hospital still needs to fix several noncompliance issues associated with these and other incidents by June 5 or face the loss of Medicare and Medicaid funding.
But HCA has not prioritized hiring and staff retention as measures to fix those issues, nurses say, despite long standing demands from union members and more recent ones from doctors, elected officials, and patient advocates.
Though Mission submitted a document in March to CMS outlining its current staffing situation and strategy, it has not committed to a plan that would meet nurses’ hiring and retention demands.
“For the past 2.5 years… Mission nurses have warned the Chief Nursing Officer, Managers on the Staffing Committee, and HCA executives about the dangers our patients face when staff is stretched so thin,” nurses in union leadership told The Watchdog in a statement. With their union contract expiring July 2, nurses began negotiations April 18 with Mission for a new labor agreement.
“We’re not a lazy profession,” said Jeanne Mould, a cardiac nurse and one of three members of the union staffing committee, which meets quarterly with hospital management to try to improve working conditions. “You give us the tools we need, we’re going to work hard and do the best to keep our patients safe.”
Mould and other nurses point to lack of staff as directly contributing to incidents that put the hospital in immediate jeopardy.
“We weren’t given the tools to adequately keep patients safe… those days,” Mould said, referring to the incidents in the CMS report. “Immediate jeopardy is directly related to how well we’re staffed.”
Mission’s plan of correction was created without the input of frontline health care workers, nurses told The Watchdog. Emergency department nurse Hannah Drummond recently testified to Congress about imacts of a “deeply broken” for-profit health care system and noted the Mission staffing plan’s lack of scope.
Drummond told The Watchdog last month there recently had been a “huge increase” in the number of full-time emergency department registered nurses, though there were ongoing issues with availability of nurse technicians (sometimes called nurse aides) and CNAs (certified nursing assistants). But emergency department nurses have been getting lunch breaks, Drummond said, noting she couldn’t speak for the night shift.
“They’re showing us that it can be done and we expect the standard to be maintained,” she said.
Currently, the average emergency department census is about 70-80 patients, Drummond said, explaining that since immediate jeopardy, there were sharp declines in the number of patients visiting Mission. Months before, she said, it was consistently more than 100 patients.
The Watchdog requested Mission patient censuses between October 2023 and March 2024 but received no response.
New emergency department hires
Mission has made recent hires in its emergency department, according to its plan of correction, which was due to CMS by the first week of February.
“Mission Hospital is continuously recruiting and making efforts to retain current employees,” the plan states. “Year to date (2024) Mission hospital ED has hired 17 RN positions, 2 CNC (clinical nurse consultant) positions, and 4 StaRN (New Nurse) positions.”
Lindell, the Mission spokesperson, did not respond to questions about how many new hires were traveler nurses and how many were full-time.
Retaining nurses means purposefully cultivating a better working environment, Mould and Mullis, the union staffing committee member, told The Watchdog in a joint interview. They talked not only about nurses but about other staff who are the backbone of systems like testing and blood work, basic patient care and environmental services. They called for the hiring of more ancillary staff, more competitive wages, more time for meal breaks, and better health care benefits.
Speaking at an April 24 Land of Sky Regional Council forum on the future of health carein western North Carolina, HCA North Carolina Division President Greg Lowe talked briefly about staffing at Mission facilities.
“Every healthcare organization across the state saw massive turnover, post-COVID, a lot of burnout,” Lowe said. “And what we found is the No. 1 indicator of retention was a feeling or a sense of belonging in our organization.”
Lowe then talked about how the hospital encourages staff to engage with the community, volunteer their time and donate to charitable organizations. He did not mention the recent investigations, the finding of immediate jeopardy or operational changes that might help keep nurses and grow the local full-time registered nurse staff.
After HCA purchased Mission for $1.5 billion in 2019, the hospital was able to swell profits it made from patient care in 2021 after a swift decline in staffing levels, according to a draft report out of Wake Forest University by professor Mark Hall.
In 2019, Mission’s profits from patient care were just under $20 million, according to the draft report. By 2021, it made $221 million, ”which was eight times its profits the year prior to purchase (2018), and almost six times its four-year pre-purchase average,” the draft report stated.
Nurses required to watch videos, take interactive lessons
Though the CMS report and immediate jeopardy finding cites failures in five areas – governing body, emergency services, patients’ rights, quality assurance, and laboratory services – as contributing to the 18 incidents of death or endangerment, it also cites failures in nursing services, which the report mentions at least 45 times.
“Of course nurses could only get to what they could get to,” Mullis said, referring to that finding. “They were put in this environment where (they) don’t have the opportunity to give the highest quality care that these patients deserve.”
Since the investigation and immediate jeopardy finding, Mission has required more education from its registered nursing staff, at least 16 hours for many, according to The Watchdog’s review of education unit records. It has mandated nurses watch training videos and take interactive lessons on computers.
In February, seven doctors and three patient advocates wrote a letter to Mark Benton, chief deputy secretary for health at the North Carolina Department of Health and Human Services (NCDHHS), calling Mission’s plan of correction “insufficient” and more focused on issues with individual employees than a systemic depleting of staff and resources.
The word “education” is repeated more than 230 times in Mission’s plan of correction, “hire” 15 times and “retain” once.
“There’s no amount of additional educational modules that they can ask us to do that will improve these metrics,” emergency department nurse Tucker Richards told The Watchdog less than two months after NCDHHS told Mission leadership in a Dec. 19 letter that conditions would put the hospital in immediate jeopardy. “It definitely seems like everything is being put on our backs.”
The Watchdog asked state and federal agencies for a response. NCDHHS spokesperson Summer Tonizzo deferred to CMS.
“NCDHHS received some concerns and recommendations specific to HCA/Mission’s Plan of Correction,” Tonizzo said. “That information was shared with state regulators and with CMS.”
CMS did not respond directly to questions about whether Mission’s plan of correction should have focused more on hiring and staff retention or if agencies knew about staffing deficits in late 2023.
“An unannounced onsite assessment of the hospital will be conducted to verify compliance with the minimum quality standards,” a CMS spokesperson told The Watchdog.
Nurses criticize staffing choices
Shortly after the February letter to Benton, CMS received the three-page March 12 staffing document from Mission outlining its strategic plan for staffing, recruitment, and retention.
Union staffing committee members interviewed by The Watchdog reviewed the document point by point. Though the document shows some specifics about the hospital’s staffing plan, many were already in place or were false, misleading or insufficient, nurses contended.
Following the state and federal investigations, managemnt now is pushing nurses throughout the hospital to more rigorously document things like patient baths and meals, duties typically assigned to CNAs. But there is a deficit in CNAs in many parts of the hospital, nurses told The Watchdog, and the added documentation responsibilities are sometimes making their jobs harder.
“Starting now, baths will be given at 11 a.m. and 11 p.m. regardless of odds or evens (room numbers),” one manager told nurses in a group chat obtained by The Watchdog.
“Nurses are to help the CNAs. This is in addition to a bath on admission. This is (sic) no exceptions. This is part of an action plan that gets reported at the (associate chief nursing officer and chief nursing officer) level. If there is a circumstance … where the bath is unable to be given, the CNC/charge must be notified immediately. We cannot have a single miss,” the manager wrote.
“How is it humanly possible to wash 20 patients simultaneously during the busiest hours of the day when there aren’t even a total number of 20 staff?” a nurse asked the manager in the group chat.
“The expectation is they are completed by that time frame,” the manager replied.
Investigative reporter Victoria A. Ifatusin contributed to this report.
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 [email protected]. 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.