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Patient deaths at Mission: Report details failures and CMS accepts hospital's plan for correction

A building on the Mission Hospital campus in Asheville.
Felicia Sonmez
A building on the Mission Hospital campus in Asheville.

A report by the Centers for Medicaid and Medicare reveals the details of multiple patient safety issues including delayed treatment, failures to provide timely care and other errors that caused the hospital to face an “immediate jeopardy” designation.

Mission acknowledged the failures, in their response, called a Plan of Correction.

“The hospital's governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights to ensure a safe environment for emergency department patients; failed to maintain an organized and effective quality assessment and improvement program; failed to have an organized nursing service to meet patient care and safety needs and failed to meet the emergency needs of patients.”

In a statement Thursday night, HCA spokeswoman Nancy Lindell said federal authorities had accepted the plan and that Mission had begun making changes based on preliminary findings in December.

The 384-page report, first made public by the Asheville Watchdog, details nine incidents that took place between April 2022 to November 2023.

As a result of the findings, government investigators concluded in December that conditions at Mission Hospital pose “immediate jeopardy” to patient safety. The designation is the most serious warning a hospital can receive and can lead a facility to lose its Medicare and Medicaid funding if the problems are not quickly resolved.

In a letter earlier this month, the Centers for Medicare & Medicaid Services officially notified HCA Healthcare of the findings and gave the hospital company until Feb. 24 to rectify the issues. HCA was also required to submit a “plan of correction” by Feb. 6, but the details of the plan were not made public.

A letter from CMS officials on Thursday found Mission's Corrective Plan "to be acceptable."

"The North Carolina State Survey Agency will conduct an unannounced revisit survey on or before February 24, 2024," the letter said.

CMS guidelines state that during revisit surveys, inspectors “should verify that all elements of the removal plan have been implemented and that the actions taken were completed in a manner that eliminates the likelihood of serious injury, serious harm, serious impairment, or death.”

The health care giant also issued a memo to all staff Mission “setting expectations around responsiveness to emergent patients, as noted in the comprehensive plan of correction.”

The report documents the ways Mission says it reviewed and audited its procedures which included multiple training and education sessions for staff.

“Provider told the family that he could not help them because it was not his patient”

The nine incidents outlined in the report span a range of patients and failures.

One case was a 48-year old man who arrived at the Mission ER on a hot July day in 2022. Notes from his medical file said he was combative. He was diagnosed with meningitis and low blood pressure.

“The patient ultimately did require intubation for sedation and airway protection, his mental status continued to worsen despite Haldol and Versed,” according to the report.

Midday, he coded and was resuscitated by staff. Around 2pm, a doctor ordered a medication used to treat life-threatening low blood pressure, and it was administered more than an hour later.

Around 6pm, he coded again. One of the doctor’s notes said, “I was notified that the patient's Levophed had run dry, and that the patient had been hypotensive (low blood pressure) sometime before coding.”

One of the patient’s nurses reported that just before the code, he told his supervisor that he had five patients- a number he felt was unsafe.

He said he went to the supervisor “to discuss my assignment and the acuity of my already 4 patients, she put my dying trauma patient in the hallway, to make room for the new trauma patient even when I explained I felt my assignment was unsafe,” according to a Patient Safety Analysis report.

“This patient coding was a direct result of an unsafe and unreasonable assignment..." the pharmacist who authored the report wrote.

The man’s family was monitoring his blood pressure, and “tried to get help from a non-ER
provider who was sitting at a computer outside the room,” according to an analysis by hospital staff. “This provider told the family that he could not help them because it was not his patient. Family is irate about this,” the report said.

The patient was again resuscitated and moved to ICU where his condition declined.

Ten days later, after being told there were no signs for meaningful improvement, his family made the decision to remove the mechanical ventilation that kept him alive and to donate his kidneys.

The Statement of Deficiencies concluded that the patient’s “levophed IV infusion sustaining his blood pressure was allowed to run dry, his blood pressure dropped, he was coded for 7 minutes until the infusion was reinstated.”

“Solution to Prevent this from Recurring? Promptly follow orders..."

Just after Thanksgiving last year, a 74-year-old woman arrived at the Mission ER by ambulance around noon, according to the report.

She had complained of dizziness at her doctor’s office. Doctors gave her an insulin drip to treat what early bloodwork showed to be high glucose. She stayed in two different waiting pods throughout the day, according to the report.

Notes in her file showed hours of delay in bloodwork. An order for lactic acid was placed at about 5:30 am but blood was not drawn until almost 9:00 am. The results, showing high lactic acid, did not get reported until after 11:00am.

The hospital's incident report said just after the results came back, “(within the hour), the patient took a turn and had to be intubated at bedside and sent to ICU.” She died hours later.

The nurse’s report noted what might have been done differently, “Solution to Prevent this from Recurring? Promptly follow orders..." the report said.

The death was just one of multiple instances of Mission Health failing to adequately care for patients reported in the Statement of Deficiencies. Some of the stories are told through interviews with the doctors and nurses who treated the patients.

In August of last year, a 39-year-old patient came to the Mission ER in the late afternoon with complaints of chest pain, nausea, lightheadedness and right-side tingling for several weeks. He also had a reported history of drinking 12 beers a day.

A doctor saw the patient sweating profusely in the waiting room area and ordered IV fluids and an assessment for alcohol withdrawal. An hour later, the doctor ordered an antianxiety medication. “These orders were not implemented.” Another hour later, a multivitamin was ordered.

At about 10:30pm, there was another order for IV fluids and a blood pressure medication and another order minutes later for aspirin.

“None of these orders were implemented,” nor was an order at about 11:00pm for Phenobarbital, a medication used to control seizures. At about 1:00am, a physician's note showed the patient had a seizure and fell outside the ED waiting room area. He suffered a head injury.

An incident report summarized the situation: "Patient was in waiting room for 9 hours, did not receive any medications for alcohol withdrawal, then had a seizure and sustained a head injury..."

An interview with a doctor showed the clinician’s concerns with the system at Mission. "...With the current process it's still difficult to treat patients in the ED waiting room,” the doctor said. “The goal was for delays in care to not happen, but especially at night it occurs. I have concerns with delays in patient care.”

Several cases in the report showed Mission clinicians failing to check vital signs at regular intervals.

In the spring of 2022, an elderly patient came to the ER with an abnormal heart rhythm and an oxygen level of 94% prior to arrival. The patient’s pulse ox dropped to 90% when it was checked about an hour and 40 minutes after arrival. Less than four hours later, the patient died.

The report said there was “no evidence of oxygen administration at hospital” and the patient’s vitals were checked only once in the 5 hours and 18 minutes from the time the patient arrived to his/her death.

A 66-year old patient had chest pain and fainted at home around 6pm in October 2023 and arrived at the Emergency Room by EMS.

"Waits had gotten more common recently and it seemed like a staffing issue," according to
an EMS staff interviewed for the report.

The report said an interview revealed staff were "counting on EMS to care for (the patients)."

“Mission Nursing staff failed to accept the patient upon arrival to the ED, resulting in delayed triage, care and treatment.” The patient died just before 8pm.

Ongoing concerns about Mission care

Mission Health System had previously been a nonprofit with a strong reputation in Asheville and Western North Carolina. But after HCA Healthcare, the country’s largest for-profit hospital company, purchased the hospital system for $1.5 billion in 2019, complaints quickly began to mount.

Since then, both patients and staff have spoken out over what they say is a pattern of understaffing and a sharp decline in the quality of care at HCA-owned facilities.

Elected officials have joined them, with more than a half-dozen Buncombe and Transylvania County leaders recently calling on HCA to either put patient safety first or sell Mission Health to a nonprofit.

In recent years, Mission Hospital has seen an exodus of longtime staff as well as a flurry of lawsuits, including one from the City of Brevard, another from the City of Asheville and Buncombe County, and a third filed in December by state attorney general Josh Stein.

In his lawsuit, Stein, who is running for governor as a Democrat, argued that HCA breached the terms of its 2019 purchase agreement by failing to provide quality emergency and cancer care at Mission Hospital. HCA responded on Wednesday, asking the North Carolina Business Court to dismiss the case because the hospital did not discontinue its emergency or oncology services.

It also blamed issues in the emergency room on state regulations, the number of patients and even the nurses themselves.

“Although Mission cannot control all variables, such as when staff unexpectedly call out from scheduled shifts, Mission strives to minimize wait times in its emergency department, recognizing that wait times for individual patients reflect unique factual circumstances at the time care is sought, including patient volume, the acuity of all patients in need of care, and regulatory constraints on inpatient capacity,” HCA’s lawyers said in their filing Wednesday.

In her statement Thursday night, Lindell, the HCA spokeswoman, said the company had received feedback from patients and first responders that some of the changes it has implemented in recent months 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,” she said of the “immediate jeopardy” report.

Lilly Knoepp contributed to this report.

Laura Lee began her journalism career as a producer and booker at NPR. She returned to her native North Carolina to manage The State of Things, a live daily statewide show on WUNC. After working as a managing editor of an education journalism start-up, she became a writer and editor at a national education publication, Edutopia. She then served as the news editor at Carolina Public Press, a statewide investigative newsroom. In 2022, she worked to build collaborative coverage of elections administration and democracy in North Carolina.

Laura received her master’s in journalism from the University of Maryland and her bachelor’s degree in political science and J.D. from the University of North Carolina at Chapel Hill.
Felicia Sonmez is a reporter covering growth and development for Blue Ridge Public Radio.