by Andrew R. Jones, avlwatchdog.org
Mission Hospital risks losing Medicare and Medicaid funding because of deficiencies in care that were so severe, state inspectors concluded last month, that they “posed immediate jeopardy to patients’ health and safety,” Asheville Watchdog has learned.
“Immediate jeopardy” is the most serious deficiency possible for a hospital. The N.C. Department of Health and Human Services has recommended that Mission lose its participation in Medicare unless it quickly corrects the deficiencies, according to a letter obtained Thursday by The Watchdog.
Failure to correct the deficiencies could threaten the financial viability of the hospital system. The majority of patients in Western North Carolina are on Medicare, Medicaid or uninsured.
The Dec. 19 letter from NCDHHS to Mission CEO Chad Patrick cites nine incidents over 19 months that highlighted deficiencies in care and states that “the hospital nursing staff failed to provide a safe environment for patients presenting to the emergency department by failing to accept patients on arrival, resulting in lack of or delays with triage, assessments, monitoring and implementation of orders, including labs and telemetry.
“ED nursing staff failed to assess, monitor and evaluate patients to identify and respond to changes in patient conditions,” the letter states. “The hospital staff failed to ensure qualified staff were available to provide care and treatment for patients who arrived in the ED. The cumulative effects of these practices resulted in an unsafe environment for ED patients.”
Mission Hospital and HCA spokesperson Nancy Lindell said in an emailed statement that the hospital has received CMS’ preliminary survey results and is expecting to receive final results shortly.
“We have taken those results seriously, and there are no excuses for our patients receiving anything other than exceptional care,” Lindell said in her statement, adding the hospital has taken action to address the initial findings and is working on a plan of correction for CMS. “This is not the standard of care we expect, nor that our patients deserve, and we will work diligently to improve.”
The Centers for Medicare & Medicaid Services’ 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. … 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.”
CMS sets certain conditions that hospitals must meet to be paid for Medicare and Medicaid patients. The letter cites six of those conditions that Mission failed to meet: governing body, emergency services, nursing services, patients’ rights, quality assurance and laboratory services.
CMS is reviewing the findings, according to an agency spokesperson, and will issue Mission “a statement of deficiencies after a review of the findings has been completed.” A statement of deficiencies outlines how a health care facility has violated CMS standards.
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% or 730 of those resulted in immediate jeopardy, according to the study.
NCDHHS investigators visited the hospital over three weeks in November and December in response to complaints, the letter states. The investigation “resulted in an Immediate Jeopardy identification on December 1,” as a result of seven incidents from April 2022 to October 2023.
The investigation identified immediate jeopardy again on Dec. 9 as a result of two incidents in November, including one that occurred the week inspectors were at the hospital.
The details of the nine incidents are not yet public. CMS is reviewing the state inspectors’ findings and will issue a “statement of deficiencies.” At that point, Mission has 23 days to respond.
Union nurses at Mission and doctors who have left the system after HCA purchased it in 2019 say that the hospital corporation has purposefully understaffed the hospital and gutted it of resources, leading to risks and patient harm.
Mission nurses have sent formal complaints to NCDHHS since 2022, The Watchdog reported in late August. At that time, NCDHHS had not visited the hospital, citing its own staff shortages.
The NCDHHS inspections occurred the weeks of Nov. 13-17, Nov. 27-Dec. 1 and Dec. 4-9, according to the letter. Beginning Nov. 14, while inspectors were at the hospital, as 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 would have reduced the burden on staff.
And on Dec. 2, a day after the first immediate jeopardy designation, Mission’s chief of staff and chief medical officer sent an email to roughly 800 doctors with seemingly obvious expectations for patient safety in the emergency department: They were to respond when alerted to a patient’s loss of consciousness or “emergent” condition, and to stop to stabilize patients at risk of dying.
If CMS accepts Mission’s plan of correction, NCDHHS will revisit the hospital to determine if the conditions that constituted immediate jeopardy have been remedied and if the hospital is in compliance.
If the immediate jeopardy is removed, Mission will have 90 days to complete the corrective actions and achieve compliance, the CMS spokesperson said.
If CMS does not receive a timely plan of correction or determines that Mission has not removed the immediate jeopardy status, the spokesperson said, CMS will send a “Notice of Termination.”
Throughout 2023, N.C. Attorney General Josh Stein investigated Mission. Stein, a Democratic gubernatorial candidate, announced Dec. 14 that his office was suing HCA and the hospital, contending they have violated the asset purchase agreement regarding cancer care and emergency services at Mission Hospital. That agreement was signed when Nashville-based HCA bought Mission Health for $1.5 billion in 2019.
The lawsuit has no connection to the NCDHHS investigation, Stein told The Watchdog at the time of the announcement. The lawsuit focuses on patient safety and staffing concerns that nurses have described in their complaints to NCDHHS, including long waits in the emergency department, low chemotherapy supplies and a lack of nursing staff.
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.
[Editor’s note: This story was updated Friday, Jan. 12, to include comments from Mission Hospital and HCA spokesperson Nancy Lindell, and North Carolina Attorney General Josh Stein.]
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. To show your support for this vital public service please visit avlwatchdog.org/donate.
My partner was a transplant patient. We visited the ER in Aug, Nov, and Dec of 2022. In Dec, after sitting in the makeshift ER triage area, with only curtains separating patients sitting in chairs. The ER physician attending him told him to “Go home. You are not safe here.” He took blood and later prescribed medication. We finally went to UNC Chapel Hill ER after he did not improve. He was admitted on Jan 11th. He passed away Feb 24th, as a result of illness that took us to the ER mulitple times. This is a despicable and dangerous situation. Staff is overwhelmed and exhausted. EVS is in crisis. I have friends who still work there, (as I did) who have nowhere to go in this area. The exodus of quality medical personnel is 100% on HCA. The change to for profit medical care has brought the healthcare industry to a stand-still, especially in rural areas. Now, NC has expanded Medicaid. Where are patients supposed to go when medical staff are leaving? It’s a situation that will once again, put Asheville in the uncomfortable spotlight for deficiencies, instead of the positive aspects of this city.