This article was originally published by the Asheville Watchdog.
Documents obtained by Asheville Watchdog detail an array of staff errors, communication breakdowns and technological problems at Mission Hospital that state and federal regulators said put patients’ lives and safety at risk and that still threaten the hospital’s ability to continue receiving Medicare and Medicaid funding.
The documents — each the findings from a survey by North Carolina Department of Health and Human Services investigators, one in September and the other last month — describe overlapping problems that led the U.S. Centers for Medicare and Medicaid Services to issue a citation of immediate jeopardy, one of the most severe sanctions a hospital can face. While immediate jeopardy has been lifted, according to CMS, Mission remains out of compliance with federal rules.
The first survey, conducted over two weeks in September, recommended immediate jeopardy based on multiple deficiencies in the care of three patients. Two died — one after equipment monitoring their blood oxygen levels failed during transport, the other after he became disconnected from equipment monitoring his vital signs and went more than three hours without being checked on by nursing staff. The third was misidentified in the hospital’s information system as another patient.
“While staff do their best to provide care,” surveyors wrote, summarizing the comments of the nurse overseeing the unit where the first patient died, “it was not always safe care.”
The second survey, following investigators’ unannounced return to Mission this month, found that the hospital still had deficiencies in patients’ rights, nursing and emergency services and governance.
According to a Nov. 21 letter from CMS to Mission CEO Greg Lowe, the hospital must fix the ongoing problems or face Medicare termination, which would pose a financial catastrophe for the hospital and a crisis for the region’s healthcare apparatus.
The continued noncompliance findings suggest that regulators see these failures not just as isolated incidents but systemic problems. Staff interviewed by surveyors cited ongoing concerns ranging from technological errors to debates over staffing levels.
Hospital spokespeople have not responded to a request for comment.
The documents, which contain identical language in many sections, also describe three other cases. In one, a patient tested positive for COVID-19 and, due to a hospital error that led to it not implementing increased precautions, exposed at least 15 people to the virus. The two other cases involved nurses’ failures to follow guidelines around heart catheterizations. The documents, both titled Statement of Deficiencies and Plan of Correction, do not include the corrective steps Mission submitted in response to the immediate jeopardy finding. A CMS spokesperson on Monday morning didn’t have an immediate explanation for why those documents weren’t included.
Mission has sought to present itself as being past the threats posed by immediate jeopardy. On Nov. 21, the same day as CMS’s letter to Mission, Lowe emailed employees stating that the finding had been lifted. Though he alluded to another upcoming survey and an additional plan of correction, his tone in the email, obtained last week by The Watchdog, was uniformly positive. As he praised staff who “continued to provide compassionate and high-quality care for the people of Western North Carolina,” he made no mention of the threat the hospital still faces.
A litany of errors in telemetry patient’s death
The documents provide new details about a patient’s death that The Watchdog first reported in September. On July 23, a 72-year-old man, identified as Patient #14, arrived at Mission with chest pains and shortness of breath. Early on July 26, a patient care technician found him on the floor of his room, disconnected from his oxygen device and the telemetry equipment that allowed an off-site technician to monitor his vital signs. He was soon pronounced dead.
The surveyors found that nurses had last checked on Patient #14 at 12:24 that morning — more than three hours before he was ultimately found on the floor. In the time between, there were several signs that something was wrong. At 2:42 a.m., the remote tech monitoring the patient’s vitals tried to notify a nurse that the telemetry leads were off. He did the same two minutes later, then again at 3:09 and 3:17. At 3:12, he tried a different nurse, the one overseeing the unit, and finally reached her at 3:26 — but by then, she told him, the nurses were managing a rapid response to another patient. They “would get to (Patient #14) after they transferred the rapid response patient off the unit,” according to surveyors’ reports.
In the meantime, a respiratory therapist did check on Patient #14. But he didn’t know about the telemetry tech’s ongoing efforts to reach nurses; he later told surveyors that he assumed the telemetry leads were supposed to be disconnected. Finally, at 3:41 a.m., the telemetry tech reached the patient care tech who, a few minutes later, found Patient #14 on the floor. Almost immediately, a “Code Blue” emergency alert was initiated. The team that responded never found a pulse.
The investigation uncovered a slew of errors. The telemetry tech, when he was unable to reach the nurses, should have made an overhead call for all staff to respond. The nurse who he first tried to reach should have passed the request along to their “buddy,” a partner nurse who would have been available to check on Patient #14. And nurses violated hospital protocol by going more than two hours between checks.
The telemetry tech later told surveyors that it was a busy night and that he was finding it difficult to follow all the patients he was responsible for. According to the investigation, these telemetry technicians work 12 hour-shifts, monitoring as many as 45 patients at a time. The nurse in charge of the unit later said the unit’s ratio of five patients per nurse spread staff thin. Investigators agreed, writing that “the hospital failed to ensure adequate staff was available to assess and respond to Patient #14.”
In the wake of Patient #14’s death, The Watchdog reported in September, union nurses worried about staffing levels and Mission’s telemetry practices repeatedly requested to meet with administrators. The hospital refused.
Equipment fails and a patient dies
On Sept. 4, a 48-year-old with a history of metastatic lung cancer arrived at Mission’s emergency department, complaining of worsening shortness of breath and chronic pain around their chest tube. Patient #10, as they’re identified in the reports (which do not specify their gender), described their pain as an 8 out of 10; a medical screening report described them as “alert, in no acute distress but … moaning in discomfort.” Doctors ordered oxygen and continuous pulse oximetry, which measures the saturation of oxygen in the blood. Patient #10 was assigned a room and readied for transport.
While being transported to their room, the investigation found, the measurements of their heart rate and oxygen levels failed. The hospital staffer who moved Patient #10 later told surveyors that they were “moaning in pain” while in the elevator and, upon arriving at the stepdown unit, appeared to have a seizure. Patient #10’s family was “frantic, asking for help,” the staffer told surveyors. Though hospital personnel responded quickly, Patient #10 soon died.
The central question seemed to be whether Patient #10 was stable enough to move in the first place and, if so, what happened during the move. Their blood pressure was low — an order for morphine had to be scrapped because of it — but transport dispatch told a nurse involved in the move that that was all right, so long as they were otherwise stable. Before moving Patient #10, surveyors found, the nurse and staffer checked with a remote telemetry tech, who, according to the nurse, confirmed that their oxygen levels and heart rate were acceptable.
But the telemetry tech told surveyors that they were on the phone with the nurse for several minutes troubleshooting problems with the pulse oximeter probe. Its signal was going in and out, a problem the tech ascribed to poor wifi connection. During the transport, the tech noticed that Patient #10’s oxygen levels were dropping but couldn’t get a clear reading due to signal issues. Though hospital protocol says techs should immediately tell nurses about drops in oxygen saturation, according to the report, the tech failed to notify the unit receiving Patient #10.
The telemetry equipment used during transport has no alarm to notify in-person staff of changes in vitals on the move, a fact surveyors heard about while investigating Patient #10’s death and saw for themselves at the hospital. The surveyors learned, they wrote, that “nursing staff had ‘huge concerns’ with signal loss in the elevators for their patients on remote telemetry.”
Patient incorrectly registered with wrong medical history
Four other cases appear in the investigative documents.
Along with Patients #10 and #14, the third case that sparked the immediate jeopardy finding was that of Patient #24, a 73-year-old man who fractured his pelvis after falling off a truck. When he arrived at the hospital just after midnight on Aug. 19, a staffer registered him incorrectly as a patient with a similar name and birth date. That led to Patient #24’s medical record being filled with incorrect medical history and medication documentation, all belonging to the person he was misidentified as.
Surveyors found that this was a common problem that hospital staff struggled to manage. In the case of Patient #24, they realized the error almost immediately but took 17 hours to correct medical records, and provider notes weren’t amended for weeks. Once the patient care process had begun, the only way to fix the misidentification, surveyors found, was to go through a corporate HCA team that isn’t staffed during the early morning hours.
“If orders are already in, it is very difficult to correct,” a staff member told surveyors.
Three other cases appear in the documents. One stemmed from surveyors’ visit to Mission in September: During their Sept. 18 tour of the pulmonary unit, which had once been used as a COVID-19 ward, staff told surveyors there were no current COVID patients. But surveyors later learned that a patient in that unit had tested positive for COVID two days earlier; due to what the hospital described as a “computer programming error,” the patient’s family hadn’t been informed of the diagnosis, increased precautions such as the use of an N95 respirator weren’t implemented, and at least 15 hospital staff were exposed to the virus.
In the two other cases, investigators found that nurses had failed to follow guidelines following heart catheterizations for two patients and, in one of those cases, failed to properly document changes in the patient’s condition.
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Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Jack Evans is an investigative reporter who previously worked at the Tampa Bay Times. You can reach him via email at jevans@avlwatchdog.org. The Watchdog’s 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/.