NEW HANOVER COUNTY — Novant New Hanover Regional Medical Center is recruiting more contract labor, a recently released action plan shows, after cutting many contracts earlier this year.
The report details over 120 travel nurses have been hired between June 30 and July 22, with potentially more to come.
On Aug. 30, Novant released its action plan for addressing its “immediate jeopardy” status with the Centers for Medicare and Medicaid. The federal agency threatened to revoke NHRMC’s Medicare contract for hospital conditions that caused, or was likely to cause, serious injury, harm, impairment or death to a patient.
NHRMC’s immediate jeopardy status has since been removed.
CMS’s findings came after investigators’ observations from June 21 to June 29, around a month after Novant decided to reduce its reliance on travel nurses. Novant did not provide to PCD data on how many travel nurses contracts were cut. However, three nurses told PCD the hospital relied heavily on travelers, staffing around 30% to 50% of its departments with them.
Novant created an action plan addressing its safety violations by CMS. In multiple cases, NHRMC was cited as failing to provide adequate staffing in its emergency department and as nurses corroborated, other departments are also operating without enough people.
Therein lies the crux of NHRMC’s problem: A worker shortage affects the hospital’s ability to perform effectively in every area. If one department is understaffed, it impairs the hospital’s interconnected ecosystem.
Novant’s action plan to CMS details its efforts to increase contract labor.
In response to its dire situation — a 138:13 patient-to-nurse ratio in the ER on June 21 — Novant took measures to hire rapid response travel nurses.
According to the report, NHRMC’s chief nurse executive — who is not named, though Amy Akers holds the position according to the hospital website — requested on June 29 the use of rapid response travelers, temporary nurses who fill urgent and crucial positions. A contract with an agency — also unnamed — providing crisis response staffing within 10 days was approved on July 5.
By July 11, 20 travel nurses arrived.
In an Aug. 24 Novant press conference overviewing the action plan, Akers said Novant has been “aggressive” in its recruiting efforts. The report shows staff participated in five local hiring events since June 28.
Novant also improved its contract labor incentives.
On June 24, a new travel agency to help seek additional clinical nursing positions, including 18 specifically for the ER, was approved. Novant extended contract length up to 26 weeks and to 48 hours per week to attract candidates.
The travel nurse rate also was increased “based on area worked.” The report states contract rates for ER nurses were increased twice over the last two months, while medical/surgical, labor and delivery, and ICU rates were increased once, although the report does not detail by how much.
According to a hospital spokesperson, Novant does not share salary figures.
On June 30, the report states NHRMC had 116 active travel nurse contracts, 25 other traveler contracts and was requesting to recruit another 182 travelers.
Almost a month later, on July 22, NHRMC gained 46 active contracts and seven other traveler contracts. According to the report, 70 more contracts were confirmed with future start dates scheduled.
NHRMC requested to recruit 72 more travelers at the end of July.
As a Novant spokesperson previously told PCD, the hospital hopes to increase its contract labor to 315 positions. Novant has filled or requested 291 positions, according to the report.
As for permanent staff, on June 22, the chief nurse executive requested eight more ER nurses and 16 medical/surgical nurses — two departments that are understaffed the most, according to nurse testimony.
The report shows 88 nurse graduates started work on July 11, with 31 scheduled to begin employment by the end of August. Between July 11 and 25, 10 care associates, three ED techs, nine nurse aides and seven paramedics were hired.
Inadequate staffing was only one area of improvement addressed in Novant’s action plan to CMS. It detailed corrections in other areas, including the hospital’s triage process, refusal of care obligations, use of chemical restraints and other emergency department procedures.
The CMS report detailed many instances where the hospital’s ER triage process was not properly followed.
One victim of that shortfall, a 77-year-old woman who coded in the ER waiting room, lingered in the lobby over five hours, with her vital signs going unchecked for four — a violation of triage policy.
Novant’s plan involved reeducating nurses on the triage process, including what’s called an “ESI scale,” ranking patients based on symptom severity. The clarification of the triage policy states patients presenting an ESI of 1 will be seen immediately and 2 will be directed to the waiting room, with vitals rechecked at least every hour. ESI levels 3, 4 and 5 will be be reassessed every four hours.
The new policy, approved July 15, clarifies vitals should be rechecked as needed, not to exceed every four hours.
The report states an emergency department coordinator will review at least 20 cases of people waiting more than four hours for vital sign rechecks. That process will occur until compliance is reached for four consecutive weeks and then move to a monthly review for three consecutive months until the problems are resolved.
To keep track of patient wait times — many of which exceeded 10 hours in the CMS report — a charge nurse will oversee a tracking board that will show how many patients are in the waiting room. The board will help notify when a patient’s vitals should be reassessed.
Nurses and clinical team members will also be required to attend a huddle prior to working a shift.
NHRMC was tasked with improving its records of and decreasing its EMS turnaround time. The CMS report cited multiple instances of delays in EMS unloading, with trucks sometimes waiting for hours to get their patients into the building. Improvements there include dedicating a charge nurse to observe delays in the turnaround process between EMS vehicles and the ER. Improvements will be reviewed monthly.
Hospital staff also are mandated to improve their responses to patients that refuse care. The CMS report found multiple cases where staff did not follow protocol when patients left without being seen. The policy was reviewed and staff were educated on its requirements.
Weekly audits of 30 patients who left without treatment or against medical advice began July 22. Beginning Sept. 1, the sample size will decrease to 60 charts per month and continue until the hospital maintains compliance for four consecutive months.
NHRMC failed to properly document the use of chemical restraint, or sedation, in multiple cases of combative patients. A facility is allowed to use certain medications on a patient that puts staff or other patients in physical danger, though restraint must be documented.
Novant updated its policy on the use of chemical restraints. Staff must document every 15 minutes per hour, every 30 minutes per hour, or hourly per two hours unless otherwise determined by the chemical restraint provider. A manager of patient safety will complete a daily review of chemical restraint orders to monitor compliance. The policy went into effect July 24.
Data on use of chemical restraints will be reported until compliance is reached for three consecutive months, then reviewed quarterly thereafter.
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