Cape Fear Valley Medical Center in Fayetteville, seen here in 2021. Melissa Sue Gerrits / Carolina Public Press

When Pamela Carver finished reading a letter from Cape Fear Valley Medical Center, her first thought was a question.

“Why is the lawyer responding instead of the CEO’s office?” said Carver, president of the Fayetteville chapter of the National Organization for Women.

The hospital then suggested the nonprofit organization, and others like it, could help provide “opportunities” for the hospital’s nurses to get certified training to treat people who come to the hospital after they are sexually assaulted.

While nurses who don’t have sexual assault nurse examiner training and certification to treat sexual assault victims can and do treat them, treatment by someone with the SANE credential is seen by many — including law enforcement — as the best option after an assault.

Getting the credential takes dozens of hours of training and clinical work, and they must pass an exam by the International Association of Forensic Nurses.

Cape Fear Valley Medical Center said in a survey response to Carolina Public Press last year that it had zero of these highly qualified nurses but clarified in January it did have eight people who had taken some training.

In late January, the NOW chapter sent a letter to hospital CEO Michael Nagowski about its concern over the lack of certified SANE nurses at the hospital, which has among the largest emergency room volumes in the nation.

The letter to the hospital came as a result of a CPP report about a lack of certified SANE nurses, largely in rural areas, with most urban hospitals largely having at least one certified SANE nurse. Cape Fear Valley Medical Center was an exception in that regard.

CPP surveyed 130 hospitals and community programs to try to find where SANE nurses were located because no state agency tracks where they are.

Carver’s letter to Nagowski in January said, “As an organization with members that serve as trained advocates to rape victims, that supports Rape Crisis of Cumberland County, we are very concerned.”

The following month, she received a reply from the health system, authored by chief legal officer Thomas Powell, that said, “While we certainly would like to have certified SANE nurses available on a continuous basis, we currently do not.”

The letter continued: “Should your organization or other similarly focused entities wish to provide SANE nurse and/or additional SANE certification opportunities, we would be glad to facilitate contact between you and the Cape Fear Valley Foundation to explore that possibility.”

Carver disputed the idea that organizations like hers needed to “provide” anything to the hospital or its foundation, which could ask the legislature for support if they needed help paying for the training, she said.

Until recently, multiple people and organizations were in the dark about the hospital’s lack of fully trained and credentialed SANE nurses, Carver said.

“None of these people were aware that there were none or that there was even a shortage until you did the survey,” Carver said. The pandemic forced victim advocates out of the hospital; otherwise, they would have known, she said.

“To me it’s an example of their lack of concern,” Carver said. “These victims of sexual assault are being revictimized by the system that’s not placing a priority (on their care). They are just getting the basics.”

She said she didn’t know why the hospital was suggesting her nonprofit could help secure training for the nurses, which she interpreted as being asked to pay for the training.

However, a program already exists in North Carolina that pays the cost of clinical training, classroom training, exam preparation and the cost of the 200-question, four-hour exam to get SANE nurse certification.

While the grant-funded program is winding down, it is still accepting nurses who have already begun the process and only need to complete the clinical or exam portions to become certified.

Hospital organization

The Internal Revenue Service considers Cape Fear Valley Medical Center and its associated hospitals a nonprofit organization. As such, the IRS requires Cape Fear Valley Medical Center to post a filing each year that outlines its expenses, revenues and other details about its operations. 

The Cumberland County Board of Commissioners, along with the county manager, serve on Cape Fear Valley Medical Center’s board of trustees — half of the board’s 16 seats.

The hospital’s most recently posted nonprofit filing with the IRS shows it earned more than $30 million in profits for its 2019 filing. The previous year the hospital netted nearly $52 million in profits after expenses, the forms show.

The documents show Nagowski earned more than $1.2 million in tax year 2017 and more than $1.8 million the following year working for the nonprofit hospital.

The hospital foundation — called the Cape Fear Valley Hospital, Auxiliary Inc. on tax documents — netted $216,620 in the 2019 tax year, after expenses.

The hospital system also accepted more than $16 million in federal CARES Act payments as part of a bailout passed by Congress last year to help rural hospitals weather the coronavirus pandemic.

The letter gave Carver and others pause.

“Do they do anything already in the foundation to offer these registered nurses this training opportunity, instead of putting the onus on us to try to get someone to help the victims? They are the caregivers of the community,” Carver said.

The hospital’s answer to NOW shows “that they haven’t prioritized this,” said Monika Johnson Hostler, executive director of N.C. Coalition Against Sexual Assault.

For counties that do have comprehensive SANE programs, “the DAs and police and victims all would say it’s the best thing that provides a comprehensive approach to addressing sexual assault in the community,” Johnson Hostler said in March.

Officials in Orange County, she said, strongly support the SANE program at UNC Hospital. 

“I don’t know what it takes to get other hospitals on board,” Johnson Hostler said. “That’s been the dilemma for my entire career.”

Training available for nurses

Though Cape Fear Valley’s letter suggested other organizations could provide “opportunities” for training, a grant-funded program at UNC Medical Center Chapel Hill pays for training and exam costs for SANE nurses right now.

While the program is winding down and not accepting new students, any nurses in the state who have already completed some or most training can receive funds for exam fees and test preparation. They can also finish their clinical hours in the waning months of this grant, said Betty Nance-Floyd, SANE program project director.

Over the nearly three years of the grant, the program has helped dozens of nurses — initially with the Vidant Health’s system but now from across North Carolina — complete their 40 hours of required training, dozens of hours of clinical work or their exam to get a certification as an adult or pediatric SANE nurse.

The program paid for transportation, hotel stays, the cost of instructors and for medically accurate models of the pelvic region, cameras and more so nurses could properly train to help sexual assault victims. In exchange, hospitals had to agree to pay for much of the nurse’s time while training.

The $1.5 million grant is coming to an end — Nance-Floyd said she’s asking for a one-year extension — but room remains for nurses who are close to completing their credentials to have the grant pay for their exam fees and test preparation.

Hospitals not required to have SANE nurses

Johnson Hostler said SANE nurses “are helpful at every level and step of this process” — clearly to the victims, but also to prosecutors who want experts to handle forensic evidence left behind by assailants.

“There’s nothing to make them currently in any state or federal law that requires them to have SANE programs,” Johnson Hostler said. “But we’re essentially hoping as advocates that they will see this as a necessary and important part of medical treatment and care, and believe in and support these programs.”

Chaka Jordan, spokeswoman for Cape Fear Valley Medical Center, said of the eight nurses who have had SANE training, one is now certified. The other seven have completed a 40-hour, web-based course from the International Association of Forensic Nurses Assault Education Course for adults/adolescents and pediatric patients.

The exams are in April and September.

When asked if the hospital was aware of UNC’s training program, Jordan said the hospital is “challenged, like most health care providers, for nursing staff during the pandemic.”

“For the convenience of our nurses, our preference is to provide the final stage of the training on-site, so our nurses do not have to take additional time off to complete the training,” Jordan said. “We are awaiting approval of on-site training by regulatory authorities.”

Creative Commons License

This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License. You may republish our stories for free, online or in print. Simply copy and paste the article contents from the box below. Note, some images and interactive features may not be included here.

Kate Martin is lead investigative reporter for Carolina Public Press. Email her at