A patient at North Suburban Medical Center died this spring after no one was available to change the battery on a machine measuring blood oxygen levels, in what employees and inspection records reveal is only the most extreme example of dangerous understaffing of HealthOne hospitals in metro Denver.
Five nurses and a doctor who’ve worked at North Suburban and two other Denver-area hospitals owned by HealthOne told The Denver Post they were understaffed, leading in some cases to an increase in preventable pressure sores and infections, and a failure to regularly provide basic hygiene care. In interviews over four months, they all spoke on the condition of anonymity to protect their current jobs or job prospects.
Colorado Department of Public Health and Environment inspection records also showed North Suburban, in Thornton, and a fourth HealthOne hospital, The Medical Center of Aurora, had been cited for insufficient care because of low staffing. Those citations typically don’t result in penalties if a hospital corrects the issue.
The patient who died at North Suburban, who was not identified in a state inspection report, was being treated for COVID-19 on May 23. He or she was hooked up to a device called a pulse oximeter, which measures whether the blood has enough oxygen. If a patient’s oxygen levels are too low, it’s important to quickly increase oxygen flow or place the patient on a ventilator, to prevent brain damage.
When an oximeter stops working, North Suburban’s procedure is for the technician to alert a nurse, then reach out to another nurse if the problem isn’t fixed within minutes, according to the inspection report.
That didn’t happen.
The nurse the technician called first was dealing with a patient who needed close watching due to alcohol withdrawal, and was further delayed because the withdrawal patient had symptoms consistent with COVID-19 and she had to safely remove all her protective equipment before moving on to other rooms. The technician didn’t realize no one had fixed the oxygen monitor for more than half an hour, because she was busy with 46 other patients. After she made a second call, the nurse didn’t arrive for another 10 minutes.
By that point, it was too late. The patient wasn’t breathing, and was declared dead after resuscitation attempts failed, according to the state inspection report.
Another technician told inspectors she had reported she couldn’t safely monitor as many as 50 patients, as she was often asked to do, but nothing changed. The nurse who couldn’t get there in time told inspectors that when she was asked what had happened to cause the patient’s death, she told hospital leadership that insufficient staffing was to blame. They never responded, she said.
HealthOne’s staffing levels are appropriate, and multiple hospitals have been recognized by the Centers for Medicare and Medicaid Services and hospital ranker Leapfrog Group for quality care, said Stephanie Sullivan, assistant vice president of media relations and video content for HCA Healthcare, which owns the HealthOne hospitals.
HCA declined an interview request from The Post, instead answering some questions via emailed statements.
“HealthONE is proud of our long-standing commitment to providing the highest quality patient care,” Sullivan said. “Our staffing levels are appropriate and consistent with national standards and also reflect provider skill mix and patient acuity.”
All HealthOne hospitals thoroughly review what led up to any “unintended event,” such as a patient’s unexpected death, and determine whether any changes are needed, Sullivan said.
“Paramount across our entire HealthONE system is providing the highest quality care to every patient, every time,” she said.
Mistakes causing harm to patients aren’t unheard of: a patient also died at Castle Rock Adventist Hospital after insufficient oxygen monitoring in 2019, and patients didn’t always receive baths and hygiene care at Post-Acute Medical Specialty Hospital in Denver. But other Denver-area facilities’ mistakes weren’t attributed to insufficient staff, and state inspection reports didn’t show any sign employees had raised alarms fruitlessly.
“Some things get missed”
A doctor who works at North Suburban told The Post that patients have developed more preventable pressure sores and infections in recent months because no one is available to turn them in bed or clean their catheters as often as needed.
North Suburban has brought more hands onto floors by deploying paramedics and new nurses who can help with running for supplies, the doctor said, but they aren’t experienced enough for complex intensive-care work. Even things that sound simple, like turning patients, require multiple people and a great deal of care because the patients are hooked up to so many machines, he said.
That’s a particular problem for patients who have the new coronavirus, who seem to do better on their stomachs, where they can use their full lung capacity, the doctor said. A “prone” patient needs careful monitoring, because you can’t just glance in the door to see if a tube has come loose or if the patient is showing signs of distress, he said.
“You don’t want to prone somebody unless you have the nursing ratio to keep them safe,” he said.
Hospitals across the country laid off or furloughed staff this spring, as states faced with COVID-19 ordered them to stop the non-emergency services that account for a large portion of their patient volume and revenue. The nurses who spoke to The Post said their hospitals haven’t called back staff, even as the number of patients started to climb again once elective surgeries resumed.
Hospitals have moved staff around from units and clinics that offered elective services to those that needed more staff due to COVID-19, HCA’s Sullivan said.
A nurse at Presbyterian/St. Luke’s Medical Center in Denver said no one has been hurt due to low staffing on her unit, but they aren’t able to provide the usual standard of care.
“Some things get missed, like showers and turning patients so they don’t get pressure injuries,” she said.
Employees were told the hospital couldn’t bring in extra help from staffing agencies because of budget struggles, the St. Luke’s nurse said. While nearly all hospitals have lost significant revenue due to canceled non-emergency surgeries, HCA reported $1.1 billion in profit in the second quarter, much of it due to federal payments to compensate hospitals for pandemic-related costs, according to The New York Times.
The decision not to bring in contract labor was based on reduced need as the hospitals cared for fewer patients, and hospitals likely will begin using more temporary nurses as elective procedures increase, Sullivan said.
Colorado doesn’t have minimum staffing ratios for hospitals, and there’s no one right number of patients per nurse, said Julie Lonborg, senior vice president of communications and media relations for the Colorado Hospital Association. The ratio depends on how much care patients need, and if there are support staff to handle routine tasks, she said.
Federal inspectors also don’t cite a specific standard, but consider a unit understaffed when the hospital can’t provide all needed care in a reasonable amount of time.
Lonborg said she was surprised to hear reports of short staffing, when many hospitals had to reduce staff hours because of the pandemic.
“Most (hospitals) are also trying to ensure that they can avoid furloughs and layoffs and are trying to ensure that their staff have the ability to earn a full paycheck,” she said.
Staffing shortages weren’t a big problem when Presbyterian/St. Luke’s called off elective procedures, freeing up nurses who worked in the surgical unit and reducing the overall number of patients needing care, the nurse who works there said. Since they’ve restarted, however, patients are having to wait longer for help, which is a problem for those who need assistance with eating or getting to the bathroom, she said.
“It’s frustrating when I’m in a room taking care of a patient and I hear that call light going off,” she said. “Sometimes the food’s sitting there for an hour before there’s someone who can feed them.”
A nurse who works in a HealthOne rehab unit said the low staffing is contributing to burnout. Nurses are working beyond their normal hours to take care of all the patient care and documentation they have to do, because there’s no guarantee the next shift will have time to do it, she said. She asked that the hospital she works at not be identified.
“It makes a 12-hour day into a 13- or 14-hour day,” she said. “If you have another 12-hour shift the next day, you’re exhausted.”
Records show long-standing problem
Low staffing hasn’t only been a problem since COVID-19 arrived in Colorado.
An inspection in January had noted that patients on North Suburban’s medical/surgical unit sometimes waited 40 minutes or longer for help when they activated their call lights, and some didn’t receive regular hygiene care, like help brushing their teeth.
A nurse working on that unit told inspectors it was best to answer within five minutes, but that wasn’t possible because there weren’t enough nursing assistants, and the charge nurses who were supposed to oversee operations and help as needed couldn’t step in because they were responsible for their own patients.
The Medical Center of Aurora also was cited, in June 2016, because nurses assigned to cover 11 to 14 patients in the behavioral health unit didn’t give medications on time, raising the risk some patients could have seizures. In an interview with inspectors, one of the nurses said their unit was frequently short-staffed and couldn’t give out all medications on schedule.
A nurse who is employed by a staffing agency but typically works in HCA facilities said she had worked on short-staffed units, both before and after the pandemic hit. Once, she was working on a cardiac floor that was short-staffed, which created a major problem when one patient temporarily stopped breathing and another’s blood pressure dropped precipitously at the same time.
While some complications will happen even with ideal care, problems are more likely if nurses are running from room to room and don’t have time to watch closely for signs a patient may be taking a turn for the worse, she said.
“Things like that could have been prevented,” she said. “A lot of the floors are short-staffed to begin with, and now it’s even worse.”
A nurse who until recently worked at Spalding Rehabilitation Hospital’s Denver unit agreed that low staffing had been an issue for some time, but said it got worse after the pandemic hit. Many of the patients on her unit had recently undergone spinal surgery and need help sitting up or walking without injuring themselves, so it’s risky to let their call lights go unanswered for a long time, she said.
Normally, she could care for four patients during the day and five at night, the former Spalding nurse said. For the last few months, she’d been assigned six patients during the day and eight at night. That’s particularly difficult because patients tend to get confused at night and may try to get up, even if they aren’t strong enough, she said.
Hospital administration would send emails emphasizing patient safety whenever someone fell, the nurse said, but the concern rang hollow since they didn’t bring in more staff to help. She gave notice in August, when the staffing calendar showed she wouldn’t have any more help through at least September.
“You don’t care about patient safety if you’re giving a nurse eight patients,” she said.
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