This story was originally published in The Asheville Watchdog
Mission Hospital has no plans to add staff in key areas – including trauma care, security, and nursing administration – as part of its recently approved, now-contested, 95-bed acute-care expansion, according to its application to the North Carolina Department of Health and Human Services.
Despite conditional approval from NCDHHS to build its capacity up to 828 patients by 2031, a nearly 13 percent increase, Mission projects only a 3.7 percent growth in staff over the next seven years, according to the document reviewed by Asheville Watchdog.
Mission’s proposal added proportionally the fewest nurses per beds compared with fellow applicants AdventHealth Asheville, UNC Health West Medical Center and Novant Health. For registered nurses, Mission anticipates increasing the number of full-time equivalents – a commonly used measurement to standardize the number of employees by hours worked – by 8 percent, falling short of the growth in patient capacity.
These projections were made in Mission’s competitive Certificate of Need application for 129 beds earmarked for Buncombe, Graham, Madison and Yancey counties under the state’s 2025 State Medical Facilities Plan. Had Mission been approved for all of the beds, it would have grown its total patient capacity by almost 18 percent.
The Watchdog reviewed the data Mission provided in its application, signed by CEO Greg Lowe, for the full 129 beds. Mission spokesperson Nancy Lindell did not respond to an email from The Watchdog requesting information about updated numbers or the hospital’s staffing plans.
North Carolina’s CON law requires healthcare providers to obtain regulators’ permission before expanding capacity or adding certain services or facilities. In late March, DHHS conditionally awarded 34 of the 129 beds to Asheville Medical Center, operated by Novant Health, for a new facility in Arden; the remainder went to Mission.
While the numbers contained in the applications don’t capture the ratio of nurses to patients on any given shift, they reflect the total workforce that a facility can draw from to staff day and night shifts in any given hospital unit.
In its original projections for 862 beds, Mission proposed employing 673.6 full-time equivalent nurses. In comparison, Advent projected that when fully staffed, it would have the equivalent of 368.88 nurses for 222 beds and UNC projected 276.6 for its new 129 bed facility, according to their applications; Novant projected that it would employ 59.5 registered nurses for its 34-bed facility.
Other Mission support services such as occupational and physical therapy and patient relations were projected to see slight increases in staffing.
In a 146-page report laying out its reasons for awarding the 95 beds to Mission, NCDHHS pointed to the “scope of services” provided at the hospital – a Level II Trauma Center at the time of its application – as making it the most effective option among the applicants. Mission has since been elevated to a Level I Trauma Center, the only one in western North Carolina.
NCDHHS representatives declined to answer questions about the methodology used to conditionally award the beds to Mission, citing recent appeals from AdventHealth and UNC Health challenging the agency’s decision.
The approval for additional Mission beds surprised some in the community given the hospital’s recent track record. Since 2021, nine deaths and other threats to patient care linked to failures to adhere to federal safety standards have led federal regulators to place Mission in Immediate Jeopardy, meaning the hospital could lose access to Medicare and Medicaid reimbursements, which would be financially catastrophic. Regulators and advocates have consistently linked these issues to the reduction in staff following HCA Healthcare’s 2019 purchase of the Mission Health system.
“Right now Mission should be in the business of staffing up,” said state Sen. Julie Mayfield, D-Buncombe and a founder of Reclaim Healthcare WNC, a coalition calling for increased accountability for HCA and Mission. “To hear those numbers says to me that perhaps they are still not understanding the connection between sufficient staffing and higher-quality care and patient experience.”
More beds follow fewer staff
The projections come amid criticism of Mission and HCA over short staffing and the increasing number of patients each nurse is expected to care for in a shift.
In comments at the company’s recent shareholders meeting, HCA CEO Sam Hazen acknowledged the “significant workforce deficit.” at Mission.
“We’re having to bring in labor – nursing (and) non-nursing – to support the demand,” Hazen said. The problem, Hazen explained, was compounded by the higher-than-expected number of sick people seeking care in the region.
As of Tuesday, May 5, there were 528 open positions at Mission, including 184 for nurses, according to HCA’s job portal.
Mission has recently launched hiring drives to recruit more nurses. The hospital completed a drive to hire 90 in 90 days, WLOS-TV reported Tuesday. This followed a push in September to hire 200 nurses.
Mission told NCDHHS in its application that it plans to build four floors on top of its “J tower” to accommodate the increase in acute-care beds. Despite the expansion and the hospital’s increased number of patients, patient transportation is not projected to receive any additional staff.
When support services are cut, nurses have to take on more responsibility to ensure units can function.
“We already have trouble doing our job because those departments are short,” said Alissa Gardner, a registered nurse at Mission. As it stands, Gardner said, nurses can’t reliably expect stretchers to be delivered for patients who need them because the transportation team is so understaffed. As a result, ICU nurses are having to leave their patients to go hunt down stretchers, she said.
Since 2002, peer-reviewed studies in more than 30 countries have repeatedly confirmed the correlation between more patients assigned to each nurse and worse patient outcomes. These include high rates of mortality, infection, delays in care and readmission.
“You name the bad outcome for a patient and it is more likely to happen in hospitals where nurses are caring for too many patients,” said Dr. Karen Lasater, associate professor of nursing at the University of Pennsylvania. “It’s not just a nursing issue; it affects all aspects of healthcare.”
But what drives healthcare providers to constantly squeeze nursing is that nurses don’t typically bill for their hours; they are seen as a labor cost, not a source of profit generation. As a result, Lasater argues, most healthcare providers will try to keep the numbers of nurses as low as possible.
But this has consequences not only for nurses, but the industry as a whole. “The No. 1 reason nurses leave healthcare is burnout and insufficient staffing,” Lasater said.
As Mission noted in its application, most of its beds are regularly occupied.
“The demand for inpatient services has pushed the hospital well beyond the optimal operating threshold of 78% occupancy,” Mission wrote.
From November 14, 2024, to July 31, 2025, there were 219 days when the hospital operated above 90 percent capacity, according to Mission’s application.
“When I first saw that they were approved for those beds I was pretty shocked,” said Gardner, the Mission nurse. “It’s hard to imagine that they’ll be able to effectively staff 95 more beds when they can’t even staff the beds we have right now.”
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Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Ted Clifford is The Watchdog’s investigative reporter focusing on healthcare. He can be reached at tclifford@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/.
