Saturday, June 15, 2024

Fed report confirms Novant’s insufficient staffing, nurses detail to PCD problem extends beyond ER

Novant-NHRMC has been hit hard over the last three months with understaffing and long wait times, and was found in “immediate jeopardy” by the Centers for Medicare and Medicaid Services earlier in the month. (Port City Daily/File)

[This piece is a 2023 N.C. Press Association award winner in the general news category.]

NEW HANOVER COUNTY — Alex Gwinn has never been in the military, but what she saw at Novant’s New Hanover Regional Medical Center two weeks ago, she said, could only be described as a scene from a war zone. 

“Everyone is shoulder to shoulder with each other in one big room,” Gwinn described to Port City Daily, “screaming and crying and yelling.”

It was only a day after Gwinn’s experience that regulators from the Centers for Medicare and Medicaid Services returned to NHRMC for a followup inspection after finding the hospital was in “immediate jeopardy” of losing its Medicare contract on June 29. The federal agency’s first visit was prompted by the death of a 77-year-old woman who coded in the ER waiting room. 

She complained of vomiting, weakness, inability to stand, fever at home and had a history of rectal cancer, for which she was receiving chemotherapy, according to a 95-page report CMS released to PCD. The report found the lady was not reassessed per the hospital’s triage policy and said nurses should have rechecked vital signs every four hours. 

The woman’s daughter noticed she became unresponsive after five-plus hours of waiting in the lobby. The report states a pulse was reestablished, and she was not pronounced dead until she was admitted into the ER, saw a provider, and her family decided to withdraw life-support measures. 

At the time, Novant downplayed the situation and stated no one died in the ER “lobby,” as reported by local outlets.

“How this story has been described publicly is not how things occurred, but in respect to the family we can’t comment on a specific situation at this time,” a Novant Health spokesperson told WECT June 14.

Though the patient did not technically die in the lobby, her condition worsened there, to the point of fatality. The report reveals the hospital failed to evaluate and supervise the care of the patient. One reason is due to lack of staffing.

When investigators toured the hospital on June 21, the ER had 108 beds available — up to 200 spaces with hallway beds included. The report also detailed how 138 patients were in the unit and with nursing staff of only 13.

CMS’s report was conducted to investigate the hospital’s noncompliance with one or more Medicare conditions that caused, or is likely to cause, serious injury, harm, impairment, or death to a patient. 

The elderly woman’s death was cited among at least a dozen other cases as noncompliant in several categories, including patient rights, nursing services and emergency services. CMS also found issues with NHRMC in quality assessment and performance improvement, and governing body. 

Due to the immediate jeopardy status imposed, NHRMC was at risk of losing its Medicare contract, which would prevent the facility from billing the federal program.

Novant said CMS regulators removed NHRMC from “immediate jeopardy” and returned the facility to good standing in a letter received Monday. The decision was based on a follow-up investigation conducted Aug. 11, though results have yet been made available to the public or media.  

However, Gwinn described to PCD earlier this week that her visit on Aug. 10 — one day after the CMS followup — was nothing short of “apocalyptic.”

“Whatever you imagine, the feeling while you’re there is much worse,” she said.

Gwinn, her fiancé and their 9-month-old infant arrived at the hospital by ambulance after deciding emergency attention was needed to treat their daughter’s symptoms — she wasn’t eating and was constipated. 

The family was placed in the lobby, a “makeshift ER,” she described. Patients were given chairs to sit in, separated by sheets strung between poles, almost like it was a photo backdrop. Since the patient was an infant, Gwinn said they didn’t have to wait long for care, two hours. From arrival to departure, she estimates they were there six hours, but she learned others had been there far longer. 

The length of time patients are waiting to be seen at Novant is addressed in the CMS report. It reveals hour to 10-hour wait times to receive care. 

Gwinn described a moment of elation when nurses arrived to inform an older patient he finally would receive a room. Because patients waiting in the lobby and overtaxed staff had bonded to “become a sort of community,” Gwinn said, everyone was relieved when another person was admitted.

“Multiple nurses came up to share the news because they were so happy for him,” Gwinn said. “And then I heard him say something about him having been there for two days.”

Without enough staff, space in the ER and on other floors cannot be made available for incoming patients. The CMS report found that, three weeks earlier from Gwinn’s visit, 64 out of 138 ER patients were inpatient status and waiting for bed placement. 

Gwinn said she saw the “nightmare” first hand, as her family was escorted through the department to run scans on her daughter. A nurse warned them of the grisly scene ahead, Gwinn indicated, as they weaved through a hallway of stretchers stacked foot to head. One elder was yelling in pain, while another stretcher nearby had an addict on it “freaking out.”

“There was a woman there for something drug-related just in a bikini,” Gwinn said. “She was just tossing and turning and scratching at herself. To her head, there was an old couple holding each other and crying. The next person was an amputee, laying there hooked up to an IV.” 

It was the second visit in two weeks for Gwinn. On Aug. 2 she arrived at the ER at Novant New Hanover Orthopedic Hospital on Wrightsville Avenue, not under review by CMS. She was escorted by her mother, Theresa Babb; both said the orthopedic hospital seemed to be understaffed as well. 

Gwinn’s mother posted on Facebook her daughter was placed in a “supply closet” as a temporary room; Novant told Port City Daily it was a casting room where staff mend broken bones. The room had plastic-covered chairs hanging on the wall, along with storage cabinets and shelves holding boxes of supplies. A stretcher was placed in the room for Gwinn. 

“I was fortunate,” she said. “They were actually really looking out for me for doing that because once I saw what everyone else was going through, I was lucky.” 

She said she was told there was a 100-bed wait at NHRMC. Gwinn waited one-and-a-half days before she could be transferred to the 10th floor of Novant-NHRMC. Yet, she noticed no other rooms were occupied and very little, sometimes zero, staff was at the nurses’ station.

Because Gwinn has a medical condition that can flare up at any time and trigger a hospital visit, she said she lives in constant fear of having to return to Novant facilities. 

“When I get dressed in the morning, I pick out clothes that I know would be comfortable for spending hours in a waiting room,” she said. 

How did Novant get here?

Experiences like Gwinn’s are becoming routine at Novant. A litany of complaints line the virtual walls of social media; some problems make headlines. The federal report confirmed NHRMC was not providing a safe environment for patients.

The report stated in 9 out of 10 cases, NHRMC failed to maintain adequate staffing to meet the needs of incoming patients arriving by EMS. It also did not collect accurate data for EMS vehicle turn-a round time and did not implement measures to decrease the time spent waiting to unload outside the ER. 

In the CMS report, a patient that arrived via EMS expressed he wanted to leave after not being seen for five hours. He reported suffering from vomiting. Staff called the person a taxi after they signed an EMS refusal-of-care form. 

In some cases, staff did not properly document if they informed patients of their risks before they left NHRMC. 

In half of the cases, nursing staff failed to assess, monitor and evaluate patients to identify and respond to changes in patient conditions, according to the report. 

Accounts of Novant’s lack of transparency and mismanagement date back to last year. According to nurses PCD spoke to over the last month, the problems were only exacerbated by the Covid-19 pandemic that caused 18% of healthcare workers to quit nationwide. Deteriorating conditions seemed to have increased at Novant over the last three months. 

NHRMC sent out a “mass casualty alert” on June 6 stating all five emergency departments were at surge capacity and asking staff not currently on shift to report to their respective departments immediately. Novant later said there was no mass casualty event, attributing the move to surge protocol. Yet, some employees accused Novant of intentional manipulation in the week after, saying the move was an unfair representation of events in order to increase staffing.

About a week later, the 77-year-old woman died while waiting for over five hours for care in the ER.

On July 27, the hospital postponed 26 non-life-threatening surgeries to accommodate increased admissions in the emergency department. According to a Novant Health spokesperson, the majority of cases were rescheduled as of Aug. 22.

Upon further investigation, there were not enough nursing staff to care for both the ER and routine patients.

Port City Daily talked to three nurses that work or previously worked at NHRMC — one traveling, one in critical care, and a student who completed her clinical rotations at the hospital. The latter two requested anonymity due to fear of employment repercussions and will be referred to as “Alice” and “Yasmine.”

All three nurses agreed Novant’s issues stem from understaffing, a problem universal to every hospital they’ve worked at. The difference at Novant, they corroborate — along with the CMS report — is Novant’s management of its employee shortage has resulted in overworking staff and putting patients in serious safety risk across many departments, not just the ER. 

An emergency room in crisis 

As a student at UNCW, Alice wanted to work as a nurse in Wilmington because she loves her hometown and desired to remain near family. From January 2020 to December 2021, she completed her clinical rotations, which allow students to learn via shadowing professionals. 

During that time, she worked in NHRMC’s progressive, labor and delivery, and medical/surgical units, with her one-on-one capstone course completed in the ER. 

After experiencing the chaos of NHRMC, Alice said she changed her mind about staying in Wilmington.

“The first year as a nurse is super important because you get this thorough training — it’s a steep learning curve,” Alice said. “I knew I wouldn’t get the experience I needed at Novant.” 

Alice said she also wasn’t convinced the hospital she spent two years in really wanted her. 

“The [Novant] recruiter took her sweet freaking time responding to people,” she said. “I got an offer from UNC [Medical Center Chapel Hill] before the recruiter even responded to me about a job opening.” 

After she graduated, she took the UNC job and moved.

Alice and the two other hospital employees reported nurses assigned to other floors, mostly from the medical/surgical floor, were routinely pulled to the ER because the department had limited workers and was often overrun with patients. 

Novant did not answer Port City Daily’s inquiry as to whether this practice was happening. A spokesperson stated a floating pool of experienced nurses receive daily assignments to different units depending on need, along with other nurses to support patients waiting on an inpatient bed.

“When making these decisions, our nursing leaders always consider the nurse’s individual experience level and the acuity of the patients being cared for,” a Novant spokesperson said.

Travel nurse Stephanie Jones said she saw nurses being shifted to other floors not only at NHRMC but also at Novant Health Matthews Medical Center in Matthews, North Carolina — a practice she said made her “very uncomfortable.” But when she worked at Duke University, she said there were policies in place to prevent that crossover.

“If you weren’t trained in the ER, you weren’t sent there,” Jones said. “That, in and of itself, is a safety concern. You don’t know policies; you don’t have codes to get meds; the charting process is different. It’s like walking into a first day of work on a new unit and being expected to know how to do the job.”

Alice said pulling nurses from other floors does not happen at UNC Medical Center either. 

“If we don’t have the staff, we will close rooms instead of making a nurse take on more patients,” she said. 

UNC Medical Center Chapel Hill also received an immediate jeopardy designation after CMS investigated on June 17 and found it failed to meet four conditions, including in infection control and patients’ rights. 

The nurses said maintaining standard ratios allows nurses to provide quality care to their patients, along with protecting their own safety. But when the waiting room starts to fill up, the pressure to accommodate the sick is heightened. 

That’s where triage nurses come in. Tasked with assessing the acuity level of incoming patients, the nurse will take vital signs and reassess patients’ conditions periodically. When not done thoroughly, a person’s symptoms can worsen or reach a point where he or she needs immediate care. In the case of the 77-year-old woman that coded in the ER in June, it was lethal.

When initially checked by nurse staff, the woman had a heart rate of 67 (the normal adult range is 60-100 beats per minute) and blood pressure of 87/53. Her blood pressure was taken again 30 minutes later and measured 118/55. No documentation of her condition was recorded again until five hours later, when she started coding, the CMS report noted.

One area Novant officials have focused on since June was improving its triage process and patient experience while in the ER. According to Christy Spivey, RN and senior director of nursing at Novant Health Coastal Region Emergency Services, Novant focused on providing additional triage education to its nurses and requiring staff to do frequent re-checks on patients waiting to be seen. 

Physicians have also been instructed to evaluate patients in the lobby if emergency department rooms are full, according to Spivey. At NHRMC, the rate of people that left without being seen was reduced to 3%, from 11% in June. 

Critical care nurse Yasmine told Port City Daily, in her opinion, Novant’s problems are 75% understaffing caused by nurses reassessing their place in the industry, but the other 25% has to do with the high population the hospital serves. NHRMC sees 88,000 patients a year, according to its website, across a seven-county region — one of which includes the second-fastest growing in the state, Brunswick County. 

As affirmed by the nurses, the Covid-19 isolation caused people to put off care, which could have led to more patients facing serious or chronic illnesses as the country emerges from the pandemic. At the end of the day, when preventative care is not accessible to individuals — who aren’t offered insurance, can’t afford medical bills, or do not attend regular health check-ups — the ER could wind up being an only option.

The three nurses also confirmed staff are prohibited from suggesting a patient seek care elsewhere, even if his or her condition could be solved outside of the ER or at another facility. It is seen as turning people away, according to hospital policy. 

“I want to tell people to go to urgent care, you can be seen quicker there, but I can’t do that,” Alice said. 

So if someone walks through the doors, or arrives via ambulance, he or she gets added to the often clogged queue. 

An interconnected system 

The problems at NHRMC extend beyond the emergency room. Understaffing on other hospital floors and departments affects the ER and vice versa, according to the nurses. Thus, if one area is out of balance, a ripple effect can be felt throughout the facility. 

Travel nurse Jones told Port City Daily she quit two months into her three-month contract, effective May 11. She worked in NHRMC’s acute care surgical unit overseeing pre- and postoperative patients with around 42 beds available. 

“The number one reason was the safety concern in my unit,” Jones said. “It was a mess.” 

While she was there, Jones reported nurses were always asked to take on more patients than what is considered customary due to a lack of staff. For patients with higher acuity, Jones said the standard is 3:1, but nurses at Novant-NHRMC frequently operated at 4:1. For patients admitted for routine or lower acuity surgeries, the standard is 5:1, with Novant nurses operating at 7:1. 

Novant did not provide to Port City Daily an answer on its standard ratios by press. 

“When you come out of surgery, there are astronomical amounts of things that could happen to you,” Jones said. “If I don’t have enough time to assess [my patient], and that person has a stroke, which you’re at high risk of when you get out of surgery, and that patient doesn’t have family members watching them, there’s no telling when I’ll be able to get to them.” 

There are no federal or state regulations on how many patients a nurse is responsible for, although a bill to implement nurse-to-patient ratios was introduced in the U.S. Senate last year. It stalled in the Committee on Health, Education, Labor, and Pensions. 

Not only were nurses understaffed, but nurse aides that assist with care were also in short supply, according to Jones. She said her floor needed about four aides but only operated with one or two.

“When you have seven people to take care of, who all need pain medication, have procedures, have complications that pop up, you’re relying on an aide to get patients to the bathroom, get them up and walking, help them bathe, help them shower, bring them snacks,” Jones said.

Another setback was the lack of transport staff, or people that bring patients to and from scans or other floors. Unlike other hospitals she has worked for, including Duke University, Jones said Novant transporters were not assigned to discharge patients, meaning a nurse would have to leave their other patients to go through the discharge procedure and take one person to the parking lot. 

If a nurse doesn’t have time to do this, it prevents a bed from opening up for someone that needs it in the ER. 

“It’s all an interconnected system,” Jones said. 

Critical care nurse Yasmine confirmed what Gwinn experienced firsthand weeks ago: about half of the patients in the ER are waiting for a bed on another floor. 

Making up a significant chunk of NHRMC’s floor staff were travel nurses, according to the nurses. Earlier this year, while Jones was still employed at Novant, the hospital decided to reduce NHRMC’s reliance on travel nurses. A month later, investigators showed up at the hospital.

“All of the agencies in the whole Novant system let nurses know Novant was cutting our rates, about a $20 [per hour] decrease,” Jones said. “Two weeks after that, 50% of travelers were told their contracts were being canceled by the end of May.” 

Travel nurses find jobs through agencies that contract them for a few months at a time. They typically earn a higher wage than staff nurses. But, according to Jones, there wasn’t always a huge discrepancy. 

Before the pandemic, Jones said a travel nurse with two years experience would earn wages on par with a staff nurse — around $30 to $35 an hour. When burnt-out nurses started leaving during the pandemic, Jones said rates skyrocketed due to increased demand. She reported travelers can now expect to see $60 hourly at the low-end and $100 at the high-end, depending on the market, plus food and housing stipends.

All three nurses reported that Novant seemed to lack a plan to replace the travel nurses, once the backbone of NHRMC’s staff. Yasmine, a nurse in critical care, said travel nurses made up one-third of the staff in her unit. 

Novant did not provide an answer to Port City Daily on how many travel nurse contracts were canceled and why that decision was made. Nor would it divulge salary information with Port City Daily.

Jones has her own theory.

“The big, ugly, not so secret part of healthcare is that it’s about money,” she said. “What should happen when a floor is not able to be staffed safely, is that beds should be closed. But when beds are closed, that means surgeries aren’t happening, which means money isn’t being brought in, so hospitals do not like closing beds and they don’t have to.” 

What’s next? 

To remove an immediate jeopardy status with CMS, a facility must put together a plan to remediate all of the federal agency’s concerns, with an expected date for a return to compliance. Thereafter, the agency will verify if the remediation is sufficient to remove the status, or if an involuntary termination with the facility is required. 

“Facilities are given every opportunity to resolve IJ situations and come into compliance with all federal requirements to be certified as a Medicare and Medicaid provider,” a CMS spokesperson told Port City Daily. “Involuntary termination of a Medicare provider agreement is generally the last resort after all other attempts to remedy noncompliance deficiencies at a facility have been exhausted.”

In a press conference Wednesday, Novant officials said they have put together an action plan for addressing its violations and it would be released on the CMS website in coming weeks. 

Novant’s leaders, such as Shelbourn Stevens, the president of Novant-NHRMC and Novant Health’s Coastal region, said the team is continuing to recruit full-time. According to Stevens, at least 10 ER nurses have been hired in the last two months. 

“We’ve been aggressive in recruiting,” said Amy Akers, RN and chief nurse executive of Novant Health NHRMC. 

In the last two weeks, 20 nursing positions at NHRMC have been posted to Novant’s career page. According to a Novant spokesperson, NHRMC has added 87 nurses and 26 certified nursing assistants since June. 

117 new nurse graduates have or will also be joining the team with a “mentor/coach to support them,” according to a Novant spokesperson.

Novant also reported plans to increase its travel nurses to 315 positions, up from the 275 employed now. 

However, it will have to spend more time and effort to mend its reputation with its staff and community.

“Nurses are telling me if they, or someone in their family, gets sick they are going to go to a different hospital,” Yasmine said. “They are not going to go to Novant.”

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