This article was originally published by the Asheville Watchdog.
Recent investigations reveal a series of errors and systemic issues at Mission Hospital, raising alarms about patient safety and compliance with healthcare regulations. These findings have left the hospital’s future Medicare and Medicaid funding in jeopardy, following critical evaluations by state and federal bodies.
The Asheville Watchdog obtained documentation showcasing the challenges faced by Mission Hospital, based on two surveys conducted by the North Carolina Department of Health and Human Services. These surveys highlighted overlapping problems that prompted the U.S. Centers for Medicare and Medicaid Services (CMS) to issue an immediate jeopardy citation, a severe sanction for hospitals. Although this immediate jeopardy has been lifted, further compliance issues remain unresolved, threatening the hospital’s federal funding status.
In September’s extensive survey, investigators noted significant deficiencies in patient care, resulting in the deaths of two patients. One patient died due to equipment failure during transport, while another went unchecked for hours after becoming disconnected from vital monitoring equipment. A third patient was mistakenly identified in the hospital’s system.
Surveyors reported, “While staff do their best to provide care, it was not always safe care,” reflecting on the nurse’s comments from the unit where the first patient died. The subsequent survey, conducted unannounced, discovered persistent deficiencies in patient rights, nursing services, and governance.
A letter from CMS to Mission CEO Greg Lowe dated Nov. 21 emphasized the necessity for the hospital to rectify these persistent issues, cautioning that failure to comply could result in a termination of Medicare funding. Such a loss would significantly impact the hospital’s finances and the local healthcare landscape.
Interviews with staff revealed ongoing concerns about technology failures and staffing debates, indicating systemic issues rather than isolated incidents. Despite these serious concerns, hospital representatives have not provided any comments.
The documents also describe three additional cases involving procedural failures. In one instance, a COVID-19 positive patient exposed at least 15 people due to a hospital error. Other cases noted nurses’ non-compliance with heart catheterization guidelines. However, specific corrective actions in response to these findings were not included in the documents, and a CMS spokesperson could not immediately clarify their absence.
Mission Hospital has attempted to convey that the immediate jeopardy threat has passed, with CEO Lowe informing staff of its lifting on Nov. 21. However, he did not address the ongoing compliance issues in his communication.
A Series of Fatal Errors
The investigation provides detailed accounts of the incidents, including a 72-year-old patient’s death, as previously reported by The Watchdog. On July 23, the patient, identified as Patient #14, was admitted with chest pains. By July 26, he was found unresponsive, disconnected from his oxygen and telemetry equipment. Despite repeated attempts by a telemetry technician to alert the nursing staff, the patient was not checked for over three hours and was later pronounced dead.
The investigation found significant lapses, including the technician’s failure to escalate the issue and nurses’ neglect to adhere to protocol by not checking on the patient within the required time frame. The tech admitted to struggling with the workload, monitoring up to 45 patients during a 12-hour shift. Investigators highlighted insufficient staffing levels, noting that the unit’s nurse-to-patient ratio compromised patient care.
In light of Patient #14’s death, union nurses expressed concerns about staffing and telemetry practices, but their requests to meet with administration were denied.
Equipment Malfunctions and Patient Death
On Sept. 4, a 48-year-old patient with advanced lung cancer arrived at the emergency department. Identified as Patient #10, they experienced severe pain and breathing difficulties. During transport, their monitoring equipment failed, and despite rapid intervention, the patient succumbed.
The investigation focused on whether the patient was stable enough for transport and what occurred during the move. Despite low blood pressure, staff were informed it was acceptable to proceed with the transfer. However, telemetry techs and nurses struggled with signal issues, which hindered accurate monitoring during the move. Notably, the equipment lacked alarms to alert staff of vital changes, a concern echoed by nursing staff regarding signal loss in elevators.
Patient Misidentification and Other Errors
Two other cases highlighted procedural failures, including a 73-year-old patient, Patient #24, who was incorrectly registered, leading to inaccuracies in his medical records. Although staff quickly recognized the error, corrections were delayed, with some notes remaining incorrect for weeks.
Additional cases involved a COVID-19 exposure incident due to a programming error and two instances of nurses failing to follow post-heart catheterization protocols.
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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/.
