CMS report on Mission Hospital details deaths of patients, significant delays in care

by Andrew R. Jones, avlwatchdog.org

At least three patients died and others were endangered at Mission Hospital in 2022 and 2023 following significant delays and lapses of care in the emergency department and other areas, according to a scathing U.S. Centers for Medicare & Medicaid Services report obtained Feb. 15 by Asheville Watchdog.

The 384-page document details why CMS placed the hospital in immediate jeopardy, the most serious sanction a hospital can face. It spotlights not only patient deaths and long delays in care but also a lack of available rooms, a lack of governing bodies “responsible for the conduct of the hospital,” and multiple leadership failures.

“The hospital’s leadership failed to ensure a medical provider was responsible for monitoring and ensuring the delivery of care to patients presenting to the emergency department,” the report states.

Hospital leadership also “failed to ensure emergency care and services were provided according to policy” and “failed to ensure adverse events were documented, tracked, trended and analyzed in order to implement preventive actions and identify success of actions taken.”

While the report focuses on issues in the emergency department, it also described deficiencies in care in other areas, including the oncology unit, where it said a patient received expired chemotherapy. It also described an incident in the behavior health unit in which a child was given medication without authorization from a parent or guardian.

The report also includes Mission’s plan of correction, which it was required to submit or face loss of its Medicare and Medicaid funding, a significant threat to its financial viability.

“We are pleased that CMS has accepted our plan of correction,” Mission health spokesperson Nancy Lindell said on Feb. 15. “Mission Health began implementing changes based on preliminary findings shared in December. We are pleased to hear from our EMS partners and patients that those actions are yielding positive results, including decreased wait times for care.

“Again, these findings are not the standard of care we expect, nor that our patients deserve, and we are working diligently to ensure Mission Hospital successfully serves the needs of the Western North Carolina community.”

The report chronicles numerous breakdowns and delays in care and details the deaths of at least three patients in the emergency department or intensive care unit.

Patient #2: ‘Delayed triage, care, and treatment’

The report lists a 66-year-old male as patient #2, who was brought into the ED shortly before 6 p.m. on Oct. 17, 2023, with chest pain after fainting at home. A physician assistant interviewed in the report said there were no rooms available when the man arrived.

That PA “saw the patient while in the hallway and placed orders.” The PA’s interview also revealed “the patient had not been triaged, he was still in the hall,” the report states.

“The provider ordered labs at [6:41 p.m.] (48 minutes after Patient #2 arrived), and the labs were not collected by nursing staff until [7:20 p.m.] (39 minutes after the lab were ordered), after the patient was triaged at [7 p.m.] (1 hour and 7 minutes after arrival).”

Patient #2 was on a cardiac monitor and received vital signs by EMS until triage at 7 p.m., according to the report, but no hospital EKG was obtained until 7:05 p.m, 24 minutes after ordered and one hour and 12 minutes after the patient arrived at the hospital.

At 7:53 p.m., amid other delays, a physician responded to the patient’s bedside because the patient was having a heart attack. “CPR was started and the patient expired,” the report states. A doctor interviewed in the report said efforts to resuscitate the man lasted for about 30 minutes.

“Nursing staff failed to accept the patient upon arrival to the ED, resulting in delayed triage, care and treatment,” the report states.

Patient #29: Left alone and unmonitored in hallway 

In another case, patient #29, a 78-year-old woman, arrived at the hospital via EMS at 2:51 p.m. on April 5, 2022, with abnormal heart rhythms. She had fallen at home and had an open fracture of her right shin bone. A pulse oximetry reading in the ambulance was 94%, but no oxygen was administered. Another pulse oximetry reading more than an hour and a half later was even lower, at 90%, but again no oxygen was given.

Nurses gave her narcotic pain medication at 4:30 p.m. and 6:16 p.m., but did not take her vital signs or check her oxygen levels afterward.

Shortly after 7 p.m., “the patient was subsequently found unresponsive in a hallway bed, in asystole” — also known as flatlined, indicating no heart activity  — “and expired.” The report did not say why the patient had been left alone and unmonitored in the hallway.

“Nursing staff failed to reassess the patient after narcotic administration. Nursing staff failed to monitor and evaluate the patient for a change in condition (not breathing),” the report concluded.

Patient #83: A “potentially life-threatening request,” then delays

A 74-year-old woman with dizziness arrived in the emergency department from her doctor’s office at 12:16 p.m. on Nov. 28, 2023. A blood workup was ordered stat, “an emergent, potentially life-threatening request,” the report said. But her blood was not drawn for another hour and 40 minutes, and the results came back three hours and 14 minutes after the original order.

The patient’s lab work showed a critically high glucose level. An infusion of insulin was ordered but not initiated for an hour and 13 minutes. “Orders for continuous ECG (heart) monitoring placed at [12:18 p.m] and vital signs every 2 hours ordered at [5:39 p.m.] were never initiated,” the report said.

A lactic acid blood test ordered in the emergency department was not done until the patient was moved to an inpatient bed, nine hours and 41 minutes later. That test revealed a critically high level. The patient was moved to an intensive care unit and placed on a ventilator.

She died at 1:37 p.m. on Nov. 30.

Mission issues plan of correction

Mission’s plan of correction states that the hospital began to make changes on Dec. 1.

Those included a memo to all medical staff setting expectations around responsiveness to emergent patients. Asheville Watchdog detailed the email in an exclusive story on Dec. 12. At the time of the story, Lindell described the memo to The Watchdog as “a point of clarification to our team and is not new information.”

The plan states that the hospital is making permanent changes to procedures and has required staff to undergo training sessions. It also describes a series of new lab order processes and the deployment of additional equipment, such as a monitor to “Air Traffic Control (ATC) desk to display and allow total visibility of ER patients with unassigned beds in waiting room, EMS entrance and pre-arrivals.”

The plan also states that the hospital’s governing body “will provide oversight of the plan of correction implementation and sustained improvements.”

Mission nurses have said for years that HCA has purposefully understaffed numerous departments and refused to provide necessary resources for the hospital to function safely.

Nurses had sent formal complaints to the N.C. Department of Health and Human Services since early 2022, some about transfer procedures in the hospital’s emergency department that they contended endangered patients, The Watchdog reported in late August. At that time, NCDHHS had not visited the hospital, citing its own staff shortages.

Mark Klein, a vascular nurse who serves in a leadership role with the hospital’s nurses union and who helped bring several complaints about systemic and leadership failures to light in 2023, said his initial impression of the CMS report was one of “heartbreak, and, sadly validation.”

Klein remains sharply critical of the leadership of Mission and HCA Healthcare, which purchased the hospital system for $1.5 billion in 2019.

“We did the right thing by bringing HCA’s horrific, injurious, profitcentric care models to the attention of regulatory authorities,” Klein said. “I believe HCA is sincere in its desire to remove the immediate jeopardy status to ensure the protection of income streams. I do not think HCA leadership is sincere about transformative change.”

He added that “HCA egregiously understaffed the hospital, not just the ER, and it is understandable why over 50% of the ER nurses leave every year. Senior leaders who put the policies that imperiled and harmed patients in place need to be held accountable.”

NCDHHS inspections on behalf of CMS occurred at the hospital Nov. 13-17, Nov. 27-Dec. 1, and Dec. 4-9. Beginning Nov. 14, while inspectors were at the hospital, The Watchdog reported, Mission offered extra shifts to doctors in the emergency department and on Nov. 20, halted some patient transfers from other hospitals, which reduced the burden on staff.

As The Watchdog was first to report, HCA Healthcare N.C. Division President Greg Lowe announced the finding of immediate jeopardy in an email to Mission’s staff Feb. 2.

Mission has until Saturday, Feb. 24 to get the hospital out of immediate jeopardy. The state will visit soon to make sure the hospital is in compliance.

Immediate jeopardy is rare, according to a 2021 study from the National Library of Medicine, which reviewed 30,808 hospital deficiencies between 2007-17. Only 2.4%, or 730, of those resulted in immediate jeopardy, according to the study.

Separately, N.C. Attorney General Josh Stein filed a lawsuit against HCA Dec. 14, alleging it failed to comply with two of 15 commitments made when it bought the Mission Health system for $1.5 billion in 2019. Specifically, those commitments were related to keeping services in the emergency department and cancer care program open and running.

While Stein alleges that systemic breakdowns leading to exiting doctors and curbed care measures have constituted breaches of the commitments, Mission contended in a Feb. 15 response to Stein’s lawsuit that it had upheld its end of the deal and, furthermore, wasn’t required by the purchase contract to provide quality care in the first place.

The asset purchase agreement — the legal contract of the sale of Mission to HCA — is “silent as to the quantity or quality of services required” at Mission Hospital, lawyers for HCA wrote in their response. “The contractual language, as well as the underlying negotiations, demonstrate that Mission’s Hospital Service Commitments are not promises to meet subjective health care standards,” the response stated.

HCA maintains that it provides quality care. “Fact: The quality of care at Mission Hospital is among the best in the nation,” HCA’s website states.

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 reporting is made possible by donations from the community. To show your support for this vital public service go to avlwatchdog.org/donate.