Report from feds details many problems at NHRMC Emergency Room that put patients in ‘Immediate Jeopardy’

Medicare officials have now restored NHRMC to good standing, after previously threatening to terminate contract
Report from feds details many problems at NHRMC Emergency Room that put patients in ‘Immediate Jeopardy’
Published: Aug. 24, 2022 at 2:37 PM EDT
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WILMINGTON, N.C. (WECT) - It’s a 95-page report that details exactly what state health inspectors found when they went to visit Novant Health New Hanover Regional Medical Center at the end of June. The inspection was prompted by a series of patient complaints, including one about a 77-year-old cancer patient who coded in the Emergency Room lobby after waiting over 5 hours for care. She died later that night.

The report goes on to detail what happened to more than a dozen other patients who also had bad experiences after visiting NHRMC in May and June. Most of those issues appear to be directly related to the severe nursing shortage at the hospital.

While the numbers in the report only provide a snapshot from the time inspectors reviewed, they help illustrate just how dire the staffing shortages have been in recent months. Nursing shortages have resulted in some patients having to wait for over 10 hours before being seen in the Emergency Room. Ambulances are reported to have been lined up outside the hospital, with paramedics waiting for hours to unload patients. Those delays tie up limited resources, increasing the wait time for other patients at home experiencing emergencies that require an ambulance to be dispatched.

During their week-long review, inspectors for the Department of Health and Human Services (DHHS) reviewed patient charts and interviewed caregivers at the hospital to get their input on what went wrong in many of the cases in question. WECT is providing the full report for public review, but pulled highlights we found from the report below.

“The facility failed to provide a safe environment for patients presenting to the emergency department [in many sampled cases]. ED nursing staff failed to assess, monitor and evaluate patients to identify and respond to changes in patient conditions. The facility staff failed to ensure qualified staff were available to provide care and treatment for patients who arrived in the ED. The cumulative effects of these practices resulted in an unsafe environment for ED patients,” the report reads in an overview of the problems inspectors found.

Ambulance Unloading Delays

According to the interview with Emergency Department Director #14, “[T]he expectation for EMS offloading time was 30 minutes...[and] ED staff were expected to accept the patient within 30 minutes of arrival to the facility.” But on June 13, Patient #6, an 83-year-old female, arrived at the hospital via ambulance suffering from “increased confusion.” The patient was transported to the ED hallway on a stretcher, and at the request of a nurse, evaluated by a doctor for possible stroke symptoms. The doctor determined she did not meet stroke criteria, and said the patient would have to wait for a room. The hospital does not appear to have taken the patient into their care at that time, because the paramedics stayed to supervise her.

“Interview [with Paramedic #25] revealed after the doctor evaluated Patient #6, Paramedic #25 waited with Patient #6 to get an ED bed.... Patient #6 went from acting sweet to acting ugly and took off all her clothing. Interview revealed Paramedic #25 updated the triage nurse on the change in condition. Interview revealed Paramedic #25 was worried about the neurologic state of Patient #6 with the sudden change,” page 22 of the report reads. It indicates Paramedic #25 waited with the patient for five hours before the next EMS crew took over.

Another case involved patient #31, a 92-year-old female who came to the hospital by ambulance on May 31st after fainting.

“After extensive wait time, EMS asked triage if patient could be triaged... Triage nurse declined [saying] she did not want patient to sit in the lobby with family due to [the fainting] episode as patient’s chief complaint. Charge nurse was consulted and she advised patient could not be triaged for same. EMS notified the wait time could extend another 9 hours possibly. Patient and family were advised of further extended wait times. Patient and patient’s family decided to take patient to another facility for treatment.... EMS assisted patient transferring from wheelchair to front seat of POV (privately owned vehicle). Patient #31 signed an EMS Refusal releasing them from EMS care... Patient #31 left the facility with family after waiting 3 hours and 48 minutes,” page 23 of the report reads.

The inspector’s interview with the charge nurse on June 13 revealed that when he got to work that night at 7pm, there were 164 patients in the Emergency Department and 13 ambulances waiting for their patients to be offloaded. Despite these and other reports, an interview with ED Medical Director #9 on June 29 “revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS.”

Inaccurate Wait Times

On page 28, inspectors detail an incident with patient #29, a 53-year-old man brought to the hospital on June 13 for an “altered mental status.”

“Review of the ED Timeline revealed the hospital never documented Patient #29′s arrival in the ED. Review revealed Patient #29 had blood collected for lab test at 1527 by ‘EMS Collector’. Review revealed the ED disposition was set to ‘Leave Without Being Seen [LWBS] before Triage’ on 06/14/2022 at 0101 (10 hours after EMS arrived with the patient). Review of the medical record revealed no Medical Screening Exam (MSE) and no documentation of risk and benefits were discussed with Patient #29 by hospital staff prior to him leaving the ED,” the report reads. The report indicates that paramedics had been standing by with the patient for the entire time he waited to be seen.

Patient #30 was a 76-year-old female brought to the NHRMC Emergency Room on May 23rd via ambulance for vomiting.

“Review of the ED Timeline revealed the hospital documented Patient #30′s arrival in the ED as 0139 (4 hours 47 minutes after EMS arrived with the patient). Review revealed the ED disposition was set to “LWBS before Triage” at 0142 (4 hours 50 minutes). Review of the medical record revealed no MSE and no documentation of risk and benefits were discussed with Patient #30 by hospital staff prior to her leaving the ED,” the report reads on page 29.

An interview with Paramedic #28, who transported Patient #30 to the ED, said “there were already 3 or 4 other EMS with stretchers with patients waiting to be seen.” He indicated that at some point while they were waiting, a hospital staff member came and put a wrist band on the patient, but “the charge nurse notified Paramedic #28 that Patient #30 did not need to sign anything for the hospital because they were not a patient of the hospital.”

While at the hospital, inspectors reviewed a report generated at NHRMC which showed a delay in turnaround time for ambulances at the 17th Street campus.

“Review revealed the facility identified the concern of EMS turnaround time in October 2021, and metrics to be measured included: EMS turnaround time (from EMS arrival to RN [registered nurse] handoff) and Outliers > 90 minutes. ‘Background information/Baseline data: Turnaround times now average 65 minutes.’ Review of ‘Tactic: ‘Arrive’ in Epic [computer program name] at true time of arrival’ revealed ‘Steps: Looking for resources to ‘arrive’ EMS patients.’ Review revealed no update was listed. Review of ‘Tactic: Staffing Redesign’ revealed Steps: labor market assessment tool approval to be completed by 02/25/2022. No further status updates were provided. Review of the data collected did not reflect the actual arrival time of the patients via EMS. The data collected was based on the time the nurses accepted the patients from EMS staff regardless of actual arrival time to the facility. Review revealed inaccurate data collection of patients presenting to the ED via EMS,” the report reads on page 46.

“Didn’t want to... lose them” in the lobby

An interview with the Performance Improvement Coordinator for Emergency Services on page 47 indicates why EMTs were being asked to stay so long after they brought their patients to the Emergency Room.

“The facility had designated a hallway in the ED for the EMS to hold the patients awaiting acceptance by the staff. Interview revealed, ‘We didn`t want to put EMS patients in the ED lobby’ because ‘they were priority and we didn`t want to lose them’ in the lobby. Interview revealed lack of staff to accept patients from EMS was identified as the main reason for EMS holding patients in the ED,” the report reads.

Summer rush

Wait times got significantly worse in June, perhaps because of the influx of people to the Wilmington area during the busy summer season. A review starting 1/1/2022 through 6/26/2022 showed 1,249 EMS trips (out of a total 1,801) resulted in turnaround times greater than 30 minutes, but only 42 trips out of the year-long total at that point had resulted in wait times over four hours. A review of turnaround times dated 6/6/2022 through 6/20/2022 revealed 944 EMS trips. 404 of those trips resulted in an EMT time of greater than the 30 minute turnaround time goal. 26 of the trips had a turnaround time of greater than four hours.

The inspector’s review of electronic medical record patient volumes showed that on June 14, a Tuesday, there were 200 patients being cared for in the NHRMC Emergency Room. 96 of them were true Emergency Department patients, but another 45 of them were Behavioral Health patients, and 59 more were impatient waiting to be assigned to a room. While there have been well over 100 empty beds at the hospital at many times over the last year, there have not been enough nurses to staff them.

On June 21, when the state inspector arrived on premises, the ED had 138 patients in the unit, with 64 patients at inpatient status and waiting for bed placement. The inspector reported that at 11:55 that night, there were only 13 nurses on hand to handle all of those patients.

Hiring surge

The hospital has about 2,000 nurses on staff. At the peak of the nursing shortage, NHRMC was short about 400 nurses. After a recent hiring surge, which was accelerated after federal healthcare regulators threatened to terminate the hospital’s Medicare contract due to patient safety concerns, NHRMC says it has been able to reduce the number of nursing vacancies to about 100.

During a reinspection on August 11, state inspectors found that hospital officials had addressed the immediate patient safety concerns, and recommended that NHRMC be returned to good standing with the DHHS, so they could keep their Medicare contract. On Monday, the hospital received a letter from the Centers for Medicare and Medicaid services stating that the hospital is back “in compliance with the Medicare Conditions of Participation... Accordingly, we are removing your facility from State Survey Agency Jurisdiction.”

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