North Carolina attorney general sues HCA for lapses at Mission Health

North Carolina’s attorney general is suing HCA Healthcare, alleging the for-profit hospital chain has “degraded” the formerly nonprofit Mission Health.

Attorney general Josh Stein’s complaint, filed Thursday, accuses the country’s largest hospital chain of failing to provide the emergency and cancer care it had promised to keep intact. Its nearly 60 pages describe a catastrophic state of dysfunction at Mission’s flagship Asheville hospital. They contain stunning allegations of patients being treated in waiting areas within full view of other patients, nurses emptying trash bins and delivering food, and patients found dead in emergency room beds hours after they died.

“For-profit HCA has broken its promise to the people of western North Carolina and to my office,” Stein said in a statement. “Quality health care is too important — in some cases, a matter of life and death. But HCA apparently cares more about its profits than its patients.”

The lawsuit follows a STAT investigation into the problems that have erupted at Mission since HCA took over in early 2019. Ten current and former Mission doctors told STAT the conditions at Mission Hospital have become unsafe because so many workers left, either because they were fired or driven away by unsafe environments, tough working conditions, and low pay.

Stein says his office has fielded more than 500 complaints about Mission since HCA took over. His lawsuit claims Mission Hospital no longer meets the standards of a level II trauma center because it’s not providing the necessary emergency care. For example, best practices are for each nurse to be assigned four patients in the emergency room and two patients in the intensive care unit. The lawsuit says Mission Hospital regularly exceeds that.

With respect to cancer care, Stein notes that Mission does not employ any medical oncologists, whereas it employed five in 2021. The doctors left because they were burned out and did not have adequate staffing support, the suit said. One of those oncologists who spoke anonymously to STAT said, “I couldn’t in good faith take care of patients somewhere that I didn’t think was safe.”

Stein’s lawsuit, filed in Buncombe County Superior Court, asks the court to declare that HCA has breached its asset purchase agreement, issue a permanent injunction to restrain HCA from committing such breaches, and require HCA to provide emergency and cancer services at the level they were prior to 2019.

In an emailed comment, Mission spokesperson Nancy Lindell emphasized the fact that Stein is currently running for governor, leading with, “We are aware of the announcement Gubernatorial Candidate Stein made in Asheville today.” Lindell wrote that HCA is confident it continues to meet the obligations under the purchase agreement. She pointed out that the independent monitor appointed to oversee HCA’s compliance found no problems during its most recent review.

“Though there have been challenges, some of which we are continuing to address as we work to expand our capacity, we remain committed to serving our community,” Lindell said. “Despite the state not allowing important expansions at Mission Hospital, we will continue to fight for critical access to healthcare services for the people of Western North Carolina.”

Specifically, Stein says HCA breached a section in the purchase agreement that requires services continue to be delivered at Mission Hospital at the same level as prior to HCA’s takeover for 10 years. It includes an exception for things like “acts of nature, war, terrorist activities,” but none of those happened in this case. He sent formal notice of his finding to HCA on Oct. 31, threatening to sue if HCA did not correct the lapses.

HCA brushed off Stein’s letter at the time, writing through an attorney that Stein’s request for information was a “bald attempt to obtain pre-litigation discovery.”

Most of the complaint centers on what’s happening in Mission Hospital’s emergency department. It describes much of the waiting room being taken up by an “Internal Processing Area,” a series of bays separated by small dividers. This is where, according to the lawsuit, patients are triaged within full view of other patients in the waiting room. The bay is across from a row of chairs where patients receive intravenous treatments. These patients are not put on heart monitors or pulse oximeters, and the bays do not have basic sanitation procedures like sinks where clinicians can wash their hands. The bays and chairs are not sanitized between patients, and bodily fluids like feces and vomit are frequently seen on the floor, the lawsuit says.

Sometimes, only one nurse staffs the Internal Processing Area. if it’s full, the complaint says that means one nurse is responsible for 28 patients.

The lawsuit echoed issues raised in STAT’s reporting, including a lack of sterilized equipment, long wait times because of low staffing, and HCA’s struggle to retain qualified nurses. The complaint says about 60% of first-year nurses staffed in the Asheville emergency department left Mission this year. It notes that HCA has fired housekeepers, food service workers, and other support staff, so that nurses who are already overworked must mop, empty trash bins, and deliver food.

This understaffing puts patients’ safety at risk, the complaint says. It says patients have been found dead in emergency room beds hours after they passed. Others have gone hours without being seen by their assigned nurse.

Stein’s lawsuit says that when state health inspectors visited the emergency department last month, HCA encouraged nurses to pick up shifts “any day they wanted.” After the inspectors left, HCA again reduced staffing.

“HCA is actively choosing not to staff all the beds in the emergency department to boost profit,” the complaint says. “It is not the case that all of the beds in Mission’s emergency department are full. Rather, all of the beds that Mission chooses to staff are full.”

Stein’s lawsuit also contends that HCA’s transfer policy artificially inflates the number of patients entering its emergency department. Typically, when emergency patients are transferred to another hospital for admission, they’re admitted directly to an inpatient floor. HCA does not allow this common practice and instead requires patients transferred to Mission Hospital to present to its emergency department.

Scott Joslin, a physician who formerly led the team of hospitalists at Mission Hospital, told STAT that policy not only adds to the backlog, it results in critically ill patients getting sent back to the waiting room, where their conditions deteriorate. One patient went into respiratory failure and another in life-threatening ketoacidosis stopped receiving insulin.

The complaint also accuses HCA of impeding local governments’ ability to provide ground and air ambulance services. That’s because when ambulances show up at Mission Hospital, they’re forced to wait to offload their patients because no providers can care for them. In 2023, for example, a patient with a brain bleed was transported to Mission’s emergency department by ambulance and waited 80 minutes for a bed. A patient with a broken neck had to wait over 2 hours. A patient with stroke symptoms had to wait almost 3.

Almost daily, the lawsuit says Buncombe County, which includes Asheville, finds itself with no ambulances available out of its fleet of more than 12 because they’re waiting at Mission Hospital.

With respect to cancer care, the lawsuit says the number of fully-staffed oncology beds at Mission Hospital has dropped from 44 at the time HCA took over to 24 today. It says HCA does not maintain an adequate supply of key chemotherapy drugs or reagents necessary for lab tests because it uses a “just in time” supply chain model. Even though HCA’s current vendors can’t provide sufficient supply to meet demand, HCA is reluctant to order from anyone other than its current vendor, Parallon, a company it owns, the lawsuit says. That inadequate supply means cancer patients had had to miss chemotherapy treatments, presenting significant risks to their health.

Stein’s lawsuit notes that the region’s largest outside practice stopped providing inpatient chemotherapy to certain patients because of unsafe conditions. He said those patients must now regularly travel hours away for care. He also said that the hospital only employs one chemotherapy-trained pharmacist.

Like many of the doctors and others critical of HCA, Stein’s lawsuit at several points praised the medical providers who continue to treat patients at Mission Hospital.

“These dedicated and hardworking health care providers must find ways to care for their patients without adequate support and resources, and sometimes in unsanitary or even unsafe conditions,” the lawsuit said.

Hannah Drummond, a nurse who works in Mission Hospital’s emergency department, spoke at a press conference Stein hosted on Thursday to announce the lawsuit. Just this week, she said she worked a shift where each nurse had more than 10 patients.

“The conditions that Hospital Corporation of America have allowed to persist at Mission are shameful and unsafe,” Drummond said.