A Mission Hospital pharmacy program that provides and tracks patients’ medications to ensure their safety has been plagued by nearly constant turnover for years, Asheville Watchdog has learned.

Despite warnings from a supervisor about dangerous errors that could result from staff departures, hospital leadership did not take significant action to recruit and retain employees, even during a hospital-wide federal investigation and resulting sanctions. 

According to internal documents and emails obtained by The Watchdog, along with interviews with multiple employees, little was done in 2023 and 2024 to keep staff on the hospital’s medication reconciliation team. The team’s supervisor, Andrea Leone, was fired in May 2024 after she commented on social media about the department’s lack of staffing.

Leone filed suit against the hospital; its corporate owner, HCA Healthcare; and her direct supervisor on Dec. 13, alleging that they prevented her from making hires that would have kept her team adequately staffed and then tried to silence her. At the time of her termination, Mission said she violated a leadership code of conduct and shared proprietary information, according to the lawsuit. 

Medication reconciliation programs help prevent potentially life-threatening errors such as omissions, duplications, dosing mistakes or drug interactions through patient interviews and scrutiny of their medication records. 

Because the medication reconciliation team lacked adequate staffing, it could complete detailed medication histories for only 30 percent of patients admitted to the hospital in 2023, according to Leone and a researched presentation she gave to colleagues in March 2024. The presentation also showed there had been at least 291 medication history errors that year, 17 of which had caused harm.

The team was able to complete histories for roughly 70 percent of high-risk patients 65 years and older, according to the presentation.

Other histories, though not as comprehensive, were completed by nurses and physicians, as is typical in most hospitals across the U.S. But many patients had no history completed at all, according to the presentation. 

In the months before her litigation, Leone spoke at length to The Watchdog about her nearly three-year experience at Mission, sharing details about what she described as a program hampered by constant turnover.

“All I’m doing is hiring, interviewing, onboarding and losing people,” Leone said of her time at Mission, which started in October 2021.

The Watchdog spoke to three people who have direct knowledge of the medication reconciliation program and who have worked with Leone. All three, whose identities The Watchdog is not revealing because they fear potential retribution, said there has been significant turnover on the team for years and praised Leone’s leadership.

Leone was supposed to supervise a team of 18 people, according to the lawsuit: 10 technicians, three pharmacists, two residents and three interns.

The team currently has only two full-time pharmacists and one on call, according to one of Leone’s former colleagues. On any given day there might be only two pharmacy techs and one pharmacist working in the med rec program, the former colleague said.

Asked how many pharmacy technicians are left working in medication reconciliation, the former colleague said, “Three full time and three prn [on call]. There are supposed to be 10 full-time techs but because HCA won’t pay pharmacy techs a living wage, [people] are forced to quit. It doesn’t help when management wants to ignore people who voice their concerns about cost of living and pay. We are overworked and the bosses keep harping on the fact that we need to do more with less.” 

Another former colleague said they had witnessed high turnover in the department, noting “some people have quit due to other job opportunities.”

The Watchdog reached out to Mission Health spokesperson Nancy Lindell twice with a list of detailed questions about the medication reconciliation program and its staffing challenges.

She acknowledged in September that the department had several open positions, though she did not specify the number. 

“The Mission Med Rec team has several open positions for which we are actively recruiting, including the role of supervisor – a role that is being filled in the interim by a qualified colleague,” Lindell said. “Market pay increases have recently been made for current employees, in addition to their many other benefits such as PTO, 401(k) matching, insurance benefits, annual merit increases, and more.”

She also noted not all hospitals have a medication reconciliation program.

“Our physicians at Mission Hospital appreciate the support of our Med Rec team but are aware of their ultimate responsibilities when it comes to the treatment provided to their patients,” Lindell said. “Whomever performs Med Rec in hospitals, it is closely monitored and regularly reviewed.”

The Watchdog reached out to Lindell again in December after Leone filed her lawsuit for an update on the team’s staffing, including whether Mission had filled Leone’s role. “We will not have anything further,” Lindell said.

Leone’s position has not been filled, one of her former colleagues told The Watchdog on Dec. 27.

‘Damned if you hire, damned if you don’t’

HCA itself affirmed the importance of medication reconciliation programs in a 2021 study created by researchers who worked at the company’s hospitals. Medication reconciliation programs, they found, unquestionably decrease errors and also increase satisfaction in the workplace. 

“A pharmacy-led medication reconciliation program involving designated pharmacists and pharmacy technicians has shown to decrease ADEs [adverse drug events] and complications while improving interdisciplinary healthcare team satisfaction.” HCA’s study said. 

If a hospital lacks a medication reconciliation program, the work of checking medication histories is often done by nurses and physicians. However, it’s ideal to have such a program, according to a 2023 study affiliated with the U.S. Department of Health and Human Services.

Research from 2022 and 2024 shows that a high turnover rate of pharmacists and pharmacy technicians creates increased risk for patient harm. 

Between 2021 and 2024, as the medication reconciliation team lost employees and recruiting stalled, the risk of errors increased, Leone said.

“What was particularly concerning was that the basics of safety, with respect to… medications, were being overlooked,” Leone said, noting another pharmacy team had flagged concerns about medication reconciliation errors in 2022.  

In November 2023, Leone expressed frustrations about turnover in an email to Mission administrators in which she advocated for a subordinate to get a raise. The email’s recipients included the subordinate. HCA reprimanded Leone in writing following the email.

Leone said that when she brought up staffing concerns with pharmacy director Sonia Lott in December 2023, “I was told to ‘let the providers complain’ and that nurses were responsible for obtaining medication histories if our team was unable to do so.”

If physicians complained, then Lott could gain leverage with leadership to keep the medication reconciliation team intact, Leone said. She added that Lott, who was hired that month, supported the team but was only one person dealing with competing priorities, including the abrupt departure of the former director six months earlier, a backlog of issues, and the federal investigation.

“I felt this was a reactive approach and explicitly communicated my dissatisfaction,” Leone said. “It did not sit well with me to allow errors to make it to the patient. How were nurses going to accomplish this if they were also short-staffed? Medication histories are a [Joint Commission] standard for accreditation and it wasn’t being done.”

The Watchdog asked Lindell, the Mission spokesperson, about Leone’s description of her interaction with Lott but did not receive a response. The Watchdog reached out directly to Lott and tried to speak to her through Mission Health communications but did not receive responses. 

Leone said the need to fill positions was acute but Mission was prohibiting most hiring, or in the case of approved hires, not offering enough pay, which meant that employees would leave shortly after they joined the staff. 

“Damned if you do hire, damned if you don’t,” Leone said.

The medication reconciliation staffing crisis intensified during one of the most tumultuous periods in the hospital’s history. 

Following an investigation, the North Carolina Department of Health and Human Services determined Mission had broken federal standards for care between 2022 and 2023, causing harm to 14 patients and the deaths of four. In February, the federal Centers for Medicare & Medicaid Services placed Mission in immediate jeopardy, the toughest sanction a hospital can face. It lifted the sanction three weeks later after determining Mission had improved conditions.

During its investigation, NCDHHS interviewed Leone about a pharmacy error that was later cited in CMS’ scathing 384-page report detailing myriad shortcomings in patient care, many of which were associated with lack of adequate staffing, a Watchdog analysis found.

“It hit home,” Leone said of the interview, “not because my team contributed to an error in any way, but I took the request for my participation extremely seriously. It shed light on how DHHS utilized the error reporting system in audits and only solidified the positive impact of our team.” 

Now with state evidence that medication reconciliation was a good program, Leone said, she left the interview hoping there would be more support for her team, but things got worse.

When Mission finalized its annual budget in December 2023, Leone said, she learned it had no plans to immediately hire for five pharmacy openings, including two on her team.

“The terminology that was being used was not clear with respect to what staffing would look like in 2024,” she said. “I was constantly getting in trouble for using the term ‘frozen.’ Leadership preferred ‘temporarily declined.’ The bottom line was that two of the five positions were taken from my team and put me in a place of not being able to recruit for months.”

When the hiring freeze went into effect in late 2023, Leone’s department was 60 percent staffed, according to her lawsuit.

“To Leone’s knowledge, HCA made this decision under the rationale that if a department had made it this far into the calendar year without such positions being filled, then whatever number of employees occupied that department were all that were necessary for the department to properly function,” the lawsuit said.

“I couldn’t fathom it, especially with immediate jeopardy, and it didn’t make sense with pharmacy being so short-staffed,” Leone told The Watchdog.

A presentation on medication errors 

The Watchdog obtained a number of emails and documents that show medication reconciliation leaders’ efforts to improve staffing amid discussions about whether the team was meeting performance metrics.

“I do want to mention that what we did discuss at length in our meeting is that we are still not meeting metrics as required such as the number of med recs/hour to be completed by each technician and what was being done to increase and get the team to meet those metrics,” Lott, the pharmacy director, told Leone in a Feb. 27, 2024, email. “Those metrics aren’t driven by the number of employees you have but in the individual performance of your team.”

In a March 2 email, Leone replied, “Yes, this will be the third time metrics have been brought up and the ultimate issues disregarded,” then added her team had been bleeding staff for years.

“We lost 1 pharmacist and four techs to turnover in the month of July,” Leone wrote. “We also lost one to injury in August [2023 for six weeks] and one returned from maternity leave at part-time end [sic] of July. Of note, I have replaced nearly every position on this team 2-3 times during my time as supervisor (not yet three years). I have recouped two tech positions since July [2023].”

Also in March, Leone showed her presentation about the 2023 medication errors to Mission doctors and a separate HCA division’s pharmacy leadership and explained how such errors might be avoided if the hospital would improve hiring and retention. 

That presentation, which was based on a limited review of cases, explained there had been at least 291 errors with patients’ medication histories in 2023, 17 of which had caused harm. A majority of the known issues happened during the admission process, according to the presentation.

“The errors that we were seeing were almost entirely preventable,” Leone told The Watchdog. 

Despite the continued turnover and the presentation, people who might have improved hiring and retention in the pharmacy department didn’t do enough to bring on more staff by late spring of 2024, Leone said.

“Pharmacists were covering tech shifts; medications were delayed,” Leone said. “Routine [paid time off] coverage was further limited. The inpatient/unit pharmacists were doing the best they could to keep up. There was a lot of concern regarding phlebotomist and lab staffing. Drug levels and cultures were being delayed, which directly affected pharmacist-led dosing.”

A plan to deal with staffing issues

Medication reconciliation staffing issues were so prevalent that on May 10, 2024, Leone’s supervisor, Christine Dresback emailed a plan to several pharmacy leaders.

Dresback wrote that the number of full-time pharmacy technicians in medication reconciliation would drop to 4.25 out of a budgeted 10.

The department was so depleted that it would have to close medication reconciliation one day a week, according to her email.

Until it could get back to a minimum of about six full-time medication reconciliation staff, Dresback wrote, it needed to reduce services and train doctors on how to make up for what the lost employees were doing. 

On May 13, Dresback contacted two doctors about the plan. 

“Unless I hear differently from you, my team will plan to communicate this to providers and implement next week,” she wrote. “We appreciate your support and help as we work to rebuild our team.”

But Jones, the vice president of operations, put a hold on the plan, saying in an email that he needed to consult with another doctor who had “significant concerns,” according to the document obtained by The Watchdog. 

This prompted Leone to email Jones, Lott, and Dresback on May 14.

“If agreeable, I would like to be part of the conversation moving forward so I can understand the general concerns and work towards resolution,” she wrote. “There are some things we can do better with respect to retention and the hiring process that may lean towards this being a more short-term versus permanent solution.”

But Leone said she never saw any effort to rebuild her team and it was unclear if there would be a long-term solution.

The Watchdog reached out directly to Jones and tried to speak to him through Mission Health communications but did not receive responses. Jones now works as chief operating officer at HCA’s North Suburban Medical Center in Denver, according to his LinkedIn profile.

The Watchdog asked Lindell if Dresback’s plan was ever implemented, but she did not respond. 

The day after her email to Jones, Lott, and Dresback, Leone wrote on the social media career website LinkedIn that there were nearly 100 open pharmacy shifts at Mission Hospital and no one to fill them. 

“I’m a pharmacist supervisor at Mission, responsible for transitions in care (primarily med histories on admission, barriers to access, safety of continued meds, and reconciliation at discharge),” Leone wrote. “The [full time employee] battle is real for all services here.  … We are constantly ‘in the red’ despite having as many as 90 open shifts not covered last schedule period. Fortunately for patients, staff picks up many extra shift[s].”

She went on to write that positions were cut because “we are considered overstaffed.”

On May 23, Leone was fired for what Mission said was a violation of HCA’s code of conduct and for sharing proprietary information about staffing. Dresback, who had developed the short-staffing plan weeks before, signed her termination papers.

Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Andrew R. Jones is a Watchdog investigative reporter. Email arjones@avlwatchdog.org. The Watchdog’s local reporting is made possible by donations from the community.  To show your support for this vital public service go to avlwatchdog.org/support-our-publication/.

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