Asheville Watchdog: Under HCA, Nurses Are Overburdened and Patients Suffer

"Oh my god, I never expected to have this many patients," said one nurse at Asheville's Mission Hospital, which shares common ownership with Transylvania Regional Hospital.

Editor’s note: This is the latest in a series of stories published by Asheville Watchdog — a free, non-profit news organization — examining for-profit HCA Healthcare’s 2019 purchase of the Mission Health system, which includes Transylvania Regional Hospital. NewsBeat is running the stories as part of a shared publishing agreement with Watchdog.

By BARBARA DURR, Asheville Watchdog

ASHEVILLE — One nurse on a surgical floor at Mission Hospital reported “patients lying in stool for an unknown amount of time,” pain medications and insulin being administered late, and “irate family members.”

A nurse caring for the sickest patients on a surgical floor at Mission documented “delayed and missed medications due to RNs having 7-8 patients . . . Inadequate staffing led to patient fall.”

Still another nurse on an intensive care and cardiac care unit reported an “inability to care for critically ill patients at appropriate high level,” resulting in an increased risk of possibly serious harm to patients.

The alarming concerns were reported by nurses on forms known as Assignment Despite Objection (ADO), a formal complaint system developed by the labor union representing Mission nurses to document unsafe assignments that, in their professional judgment, put patients at risk. The forms are completed only after the nurses have informed their supervisors with no resolution.

This is Part 2 of Asheville Watchdog's series "Mission: Doctors, Nurses, Patients." Read Part 1 here. Coming next, Part 3: Patients seek care elsewhere.

Nurses at Mission have filed more than 200 ADOs since July 2021, when the nurses’ union contract was ratified. Asheville Watchdog requested the forms from the union and obtained 45 of them with the nurses’ names and identifying information redacted.

The forms, along with interviews with current and former nurses, paint a picture of a hospital that was once highly regarded and a source of community pride, but that has degenerated, the nurses said, into a punishing workplace, where staffing reductions and shortages have diminished the quality of care. 

Mission denies that quality of care has suffered under HCA ownership and points to an “A” grade in the latest Leapfrog rating of hospital safety metrics. Mission also rightly notes that staffing shortages are a nationwide problem and not unique to Mission Hospital.

Mission Was a Family

As a nonprofit for more than a century, Mission Hospital was not only Buncombe’s largest employer but also a “destination” hospital, where nurses planned to spend their entire careers. 

“It was very much a family,” said Kelley Tyler, who has been a nurse at Mission for 36 years. “We all looked out for each other. We all celebrated and cried with each other.”

Susan Fischer, a registered nurse who has been at the hospital for 16 years, said that when she came to Mission, “I thought I had fallen into heaven. It was exactly what I always wanted nursing to be.”

The nurses said they took pride in their work and their employer. “You felt you are a part of a great thing,” Tyler said. “And I honestly can’t say that about my job now.”

After profit-focused HCA Healthcare took over from nonprofit Mission Health in 2019, nurses told Asheville Watchdog, their workload increased as management cut positions from housekeeping to food service. Nurses left, often replaced by part-time or traveling nurses, if at all. 

‘I Cannot Do It All’

Tyler’s 44-bed unit used to have one nurse for every three patients. Most days now, she said, there is one for every six. 

Tyler said she recently received a phone message for off-duty nurses from Mission that said, “ ‘We desperately need nurses. Tonight, we only have four RNs.’ “

“I mean, do the math, that’s 11 patients apiece,” Tyler said.

Claire Hubbard, who worked in the Office of Decedent Affairs before HCA eliminated it, and then became a part-time nurse, said traveling nurses at Mission told her, “ ‘Oh my god, I never expected to have this many patients.’ ”

Fischer said higher workloads mean less time for each patient. “If it is six patients, that’s 10 minutes an hour, seven patients it’s 8.5 minutes an hour, eight it’s 7.5 minutes an hour,” she said.

And some patients need more care than others. “You might walk in there and they’re incontinent,

so they must be changed first,” she said. “You could be in there 20 or 30 minutes when you were just going to pass medications.”

Mission’s patients come from across western North Carolina, where the population tends to be older and sicker than average.

Nurses have taken on other tasks as HCA cut back on support staff, including housekeeping. “We’re not beyond doing this,” Fischer said. “But when you have six, seven, eight patients … garbage is not going to be your priority.”

Recently, nurses have been asked to draw patients’ blood because of a shortage of phlebotomists, technicians who would normally perform the task, Fischer said.

Certified nursing assistants (CNAs) have also been cut. Tyler’s unit is supposed to have four, she said, but “It’s very common that we only have one or two.”

One day in September, Fischer and Tyler said, the dietary staff was so short that breakfast was not served.

“We have patients that are diabetics that absolutely need to be fed and they had no food,” Fischer said. Nurses, she said, scrounged up peanut butter crackers provided as snacks on the wards, and gave them to patients.

Fischer said traveling nurses have told her, “‘I cannot do it all.’”

Unsafe Assignments

Registered nurses at Mission, concerned about deteriorating working conditions and patient care, voted to join the National Nurses United union in September 2020. The Mission nurses who spoke to Asheville Watchdog for this story are union members.

Mission nurses have protested at union-organized rallies, including one in February over what they described as unsafe working conditions during the pandemic. In response to nurses’ complaints, the Occupational Health and Safety Division of the North Carolina Department of Labor on March 22 cited Mission and proposed nearly $30,000 in fines for violations that included failing to ensure employees wore properly fitted masks and safety equipment and not reporting an employee’s death from COVID-19.

“The safety and well-being of our patients and caregivers is our top priority,” Nancy Lindell, director of public and media relations for HCA Healthcare’s North Carolina Division, wrote in an email to news media. “We are deeply saddened by the loss of one of our caregivers. We have no evidence that directly ties their illness to the loving care they gave our patients.”

Mission has requested a conference on the citations with the Occupational Health and Safety Division, but a date has not yet been set, Jennifer Haigwood, spokeswoman for the Department of Labor, said Wednesday.

Nurses say their nursing licenses are on the line if something goes wrong. 

“Their big fear is losing their license permanently, not just losing a job at this one hospital,” Tyler said. “Management is faulting the nurses if things aren’t done right.”

Fischer said she knows of nurses who have asked for more help, and “the house supervisor has threatened them with insubordination.” The Assignment Despite Objection (ADO) forms are meant to protect nurses and their licenses. 

“Today’s assignment is unsafe and places my/our patients at risk,” the form says. “As a result, the facility is responsible for any adverse effects on patient care.”

Melanie Wetmore, Mission’s Chief Nursing Officer, said, “We have gone to great lengths to solicit the voice of our caregivers.”

In a statement to Asheville Watchdog, Wetmore said that in addition to monthly meetings, town halls, and other venues for communication such as staff meetings, “I make regular rounds on all of our hospital units to personally review operations and to speak with staff. Our supervisors are among the best I have worked with and we appreciate and respect our nursing teams at Mission Hospital.”

‘Substandard Care’

The ADOs reviewed by Asheville Watchdog show a pattern of recurring concerns: too many patients per nurse, too few nursing assistants, and delays in such essential care as administering medication and taking vital signs. 

“Patients placed inappropriately on a unit required a higher level of care than could be provided,” wrote a nurse on a medical/surgical unit.

“Meds late, unable to turn patients and stabilize per unit standards, substandard care when assignments are too heavy,” wrote a nurse in an intensive care unit.

“Full COVID unit inadequately staffed for acuity of floor,” said another.

One nursing assistant reported being bitten by a patient. 

“Personal patient care cannot be given in a timely manner when RNs have too many patients and there is 1 CNA [certified nursing assistant] for 36 patients.”

The union’s Professional Practice Committee shares the ADOs and their recommendations with Mission’s management in monthly meetings. The Chief Nursing Officer is supposed to respond with a solution within a month, according to the union contract.  

“Sometimes they ignore us or are completely dismissive of the things we recommend,” said Kelly Graham, a nurse who is on the union committee.

The union did stop one practice: placing patient beds in the hallways to reduce congestion in the emergency room, said Tyler, the long-time nurse at Mission. 

Lindell, of HCA said, “The Hospital reviews the ADO forms to assess the substance of the objection and the appropriateness of the assignment. This review is done by the supervisor and charge nurse on duty as well as by the manager and director.”

She said Mission management addresses the recommendations that come from the practice committees, and that “staffing is reviewed every 4 hours every day.” 

Nursing Shortage, then COVID

Like hospitals across the country, Mission is grappling with a shortage of nurses, exacerbated by the pandemic. Mission Health has a total of approximately 2,100 registered nurse positions, but as of March 30, a Mission job board listed 429 registered nurse openings, almost all of them in Asheville.

“The country’s critical nursing shortage reaches beyond Asheville, as estimates indicate that last year more nurses retired than ever before with an additional 500,000 retirements anticipated by 2022,” Lindell said. 

Research by the Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill estimated that the state would have a shortage of 12,500 nurses by 2033, with the greatest shortfall,10,000, in hospitals.

Lindell said Mission is recruiting to fill nursing jobs as quickly as possible and is offering signing bonuses, recruiting internationally and partnering with “multiple nursing programs.”

But on social media, Mission’s reputation under HCA may be interfering with some of those recruitment efforts. A Reddit thread on traveling nurses, for example, warns against working at Mission because of unsafe working conditions. “I’ve heard from nurses that they underpay and understaff,” one job seeker wrote.

Hannah Drummond, a former traveling nurse now on staff at Mission, said that on online traveling nurse sites, “HCA has a reputation across the country for terrible working and staffing conditions, and Mission is known within that circle well.”

Temporary Travelers Fill In

Traveling nurses, or travelers, working under contract typically for four to 13 weeks, are helping fill the gap at Mission. Healthtrust, a subsidiary of HCA, provides job placement for contract nurses, although Lindell said that travelers at Mission are not exclusively contracted through that company. 

Mission staff nurses told Asheville Watchdog that roughly half of the hospital’s nurses are now travelers, and in some units, almost all are.

On Fischer’s floor, typically just one nurse is a full-time employee, and the rest are travelers, she said. As a result, “there’s almost no continuity of care,” she said.

Travelers have been crucial to fill staffing shortages, Fischer said, but they lack a commitment to the hospital “and that makes a huge difference.”

Elle Kruta, a nurse case manager who handles patient transitions to their homes, said that employing travelers “makes good business sense, but doesn’t make good patient care.”

Some Mission nurses have left to become travelers, who typically are paid far more than staff nurses, and receive a stipend for living expenses, which staff nurses don’t receive. 

Fischer said a former Mission colleague is now a traveling nurse in South Carolina, where she cares for fewer patients and has more nursing assistants. “She feels like she can take good care of her patients now, and she’s getting paid three to four times more a week than I am,” Fischer said. 

Another Mission nurse told Fischer she’d be paid $4,100 a week as a traveler between her salary and stipend; at Mission, she makes $900 a week.

Quitting Mission, Leaving Profession

Between working conditions and the lure of travelers, nurses at Mission are leaving, with some quitting the profession entirely. 

Under HCA management, Hubbard, the former nurse in Decedent Affairs, said the nurses she knew at Mission are looking for other jobs or have gone to hospitals in nearby Hendersonville. 

Fischer said nurses stressed from caring for too many patients or acutely ill patients “with no help” have left to become travelers, or in some cases to take lower-paying office jobs. “One nurse,” she said, “actually quit the profession altogether.”

Tyler, the 36-year Mission nurse, said some travelers leave before the end of their contracts.

“If they are not willing to stick out their 13-week contract or even their four-week contract,” Tyler said, “it opens your eyes to how dire the situations and conditions are at the hospital.”

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 bdurr@avlwatchdog.org. Asheville Watchdog