Patient Suicide at Mission Hospital Sparks Concerns Over Care Standards
In a tragic incident, a patient at Mission Hospital, under an involuntary commitment order, took their own life within the psychiatric unit during the early hours of May 21. This development has been verified by Asheville Watchdog.
The unnamed patient was brought to the facility by law enforcement, as corroborated by multiple sources familiar with the situation.
The U.S. Centers for Medicare & Medicaid Services (CMS) is “aware of the reported patient suicide at Mission Hospital and takes this matter very seriously,” according to a representative.
Since HCA Healthcare’s acquisition in 2019, Mission Hospital has faced repeated sanctions by CMS due to at least nine patient deaths linked to care deficiencies. Since January, the hospital has been under “enhanced monitoring” by CMS, and surveyors were reportedly present at the hospital on Tuesday.
Mission Hospital’s representatives did not provide comments to Asheville Watchdog regarding the incident.
The suicide took place in the hospital’s emergency department “Red Pod,” a designated area for psychiatric patients, as per several sources.
Procedures and Protocols in Question
Mission Hospital’s Emergency Department is often the initial point of contact for psychiatric patients under involuntary commitment, a legal measure for those deemed a danger to themselves or others due to mental illness or substance use. Patients are assessed and stabilized here before being sent to treatment facilities or other appropriate destinations.
Patients under involuntary hold should have a “sitter” for constant monitoring. It remains unclear if this protocol was followed at the time of the patient’s death.
In response to the incident, hospital management distributed an updated policy titled “Enhanced Patient Safety Measures for Involuntary Committed (IVC) Patients.”
This policy mandates “one-to-one sitters” for patients under involuntary commitment, effective immediately. The sitter must stay with the patient until a nurse completes a “Columbia Suicide Severity Rating Scale” and a doctor conducts a risk assessment.
Staff are instructed to notify the emergency department nurse coordinator if a sitter is absent or an evaluation is pending, or if they notice “concerning items in the patient’s room.”
Ongoing Challenges at Mission Hospital
The recent death adds to the challenges facing Asheville’s primary hospital, the only Level 1 trauma center in western North Carolina. Just four months prior, Mission Hospital received an Immediate Jeopardy warning, the most severe sanction from federal regulators, signaling potential loss of Medicare and Medicaid reimbursements if issues are not resolved.
There is no requirement for public disclosure of sanctions by the hospital or state and federal investigators. The Watchdog confirmed Mission Hospital, owned by HCA, has received at least four Immediate Jeopardy warnings since 2021, citing nine deaths due to patient care deficiencies.
Among these cases, one involved a cardiac patient who died after being disconnected from monitoring for over an hour, and another involved an 88-year-old woman who waited 13 hours for a blood transfusion. However, other incidents, such as a patient who died after emergency calls went unanswered for 29 minutes, were not included in Immediate Jeopardy reports.
Though Mission resolved the Immediate Jeopardy by the end of February, CMS has placed the hospital under additional scrutiny. Due to “systemic and repeated quality concerns,” CMS required the hospital to submit and adhere to an enhanced plan of correction by July 29.
[Editor’s note: If you or someone you know are having thoughts of suicide, call or text 988 to reach the 988 Suicide and Crisis Lifeline. In addition, Crisis Text Line is a texting service for emotional crisis support. To speak with a trained listener, text HELLO to 741741. It is free, available 24/7, and confidential.]
