Mission Hospital should again be put in immediate jeopardy, the worst sanction a hospital can face, the North Carolina Department of Health and Human Services has recommended.
The finding, made by NCDHHS and reported to the U.S. Centers for Medicare & Medicaid Services (CMS), is a devastating blow to the largest healthcare provider in western North Carolina: For the second time in two years, and the third since for-profit HCA Healthcare bought the nonprofit Mission Health system in 2019, the hospital risks losing Medicare and Medicaid funding because of deficiencies in care so severe that state inspectors believe they pose imminent risk of serious injuries or death to patients.
NCDHHS notified Mission CEO Greg Lowe of its finding in a letter dated Oct. 10 and obtained Friday by Asheville Watchdog. A Mission spokesperson did not immediately respond to requests for comment.
In the letter, NCDHHS alleged that Mission failed to correct or mitigate risks concerning patient misidentification, telemetry monitoring and patient-transportation safety.
The agency, which conducted its investigation on behalf of CMS last month, flagged a series of incidents on July 26, Aug. 19, and Sept. 4. The first of those dates aligns with an incident in which a cardiac patient died after becoming disconnected from telemetry equipment, which off-site technicians use to monitor patients’ vital signs, for at least an hour. The Watchdog first reported news of the death, along with the fact that hospital administration repeatedly turned down nurses’ requests for an emergency meeting following the incident, in September.
In the other incidents, nurses “failed to ensure safe and appropriate transport and continuous pulse oximetry monitoring for a patient” and “failed to prevent and control infections by not accurately implementing and communicating infection prevention precautions,” according to the NCDHHS letter to Lowe. The agency also investigated a Sept. 18 incident related to infection prevention practices but determined that the hospital took corrective action that prevented it from rising to the level of immediate jeopardy.
“For months, bedside nurses, along with our union’s Staffing and Professional Practice Committees, have been calling on Mission Hospital to prioritize safe staffing,” said Kerri Wilson, a registered nurse in Mission’s telemetry unit and chair of the professional practice committee, in a statement provided by National Nurses United. “Instead, our concerns have been ignored while the hospital continues to put profits over patient care. The tragedies that led to this immediate jeopardy finding could have been prevented if management had listened to nurses and invested in patient safety.”
Mission’s near future now rests in the hands of the CMS’s regional office in Atlanta, which will decide whether to place the hospital in immediate jeopardy. The CMS decision could take weeks or months: When the agency placed Mission in immediate jeopardy in 2024, it did so about six weeks after NCDHHS’s letter to then-CEO Chad Patrick.
If placed in immediate jeopardy, Mission would have 23 days to issue a plan of correction or face loss of its Medicare and Medicaid funding, which would be disastrous for the hospital, which is financially dependent on that funding.
Previous immediate jeopardy findings
In early 2024, Mission was placed in immediate jeopardy after an NCDHHS inspection revealed 18 patients were harmed between 2022-2023, four of whom died, all as a result of violations of federal standards of care related to the hospital’s emergency and oncology services. The sanction was lifted after Mission provided a plan of correction within the mandated 23 days.
In 2021, Mission faced another immediate jeopardy sanction after a female patient – referred to as Patient #6 in the investigation report – was found dying on the floor of her hospital room on March 1, her IV disconnected, and saline flush syringes in her bed.
In a letter dated June 2, 2021, to Patrick, NCDHSS wrote that “the hospital failed to maintain a safe environment for a medical/surgical patient with a history of substance abuse and prevent patient access to unsecured flushes, failed to follow a physician order for liquid pain medication, and failed to communicate and escalate patient care concerns for safety.”
Two other hospitals acquired by HCA in the region have received immediate jeopardy citations following the 2019 sale — Blue Ridge Regional Hospital in Spruce Pine in 2023 and Mission Hospital McDowell in Marion in 2021.
Earlier this year, CMS also investigated an Emergency Medical Treatment and Labor Act violation at Mission after a patient died in an emergency department bathroom in February after calling for help for 29 minutes before staff responded. That investigation determined that Mission violated its responsibility to provide emergency services. But by the time of the investigation, the hospital had taken sufficient steps to remedy the problems that led to the death and avoided an immediate jeopardy finding.
CMS regulations define immediate jeopardy as noncompliance that “has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death.
“[It] is the most serious deficiency type, and carries the most serious sanctions,” according to the regulations. “An immediate jeopardy situation is one that is clearly identifiable due to the severity of its harm or likelihood for serious harm and the immediate need for it to be corrected to avoid further or future serious harm.”
Immediate jeopardy is rare, according to a 2021 study from the National Library of Medicine, which reviewed 30,808 hospital deficiencies between 2007-2017. Only 2.4 percent or 730 of those resulted in immediate jeopardy, according to the study.
With 682 licensed acute care beds, Mission is the state’s largest hospital west of Charlotte, serves tens of thousands of patients a year, and is the region’s only Level 2 trauma center. It has applied to become western North Carolina’s only Level 1 trauma center and is awaiting a decision from NCDHHS.
[Editor’s note: This story was updated at 3:29 p.m. Oct. 17 to include comment from Kerri Wilson, a registered nurse in Mission’s telemetry unit and chair of the hospital’s professional practice committee.]
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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. Andrew R. Jones is a Watchdog investigative reporter. 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/.
