Asheville Watchdog: CMS Report Dissects Widespread Failures at HCA Mission Hospital

Written by Andrew R. Jones, Asheville Watchdog.

The long-awaited report by federal investigators takes the reader behind the curtains at HCA-owned Mission Hospital, and it’s a dismal scene: hours-long delays in critical tests, patients piled in hallways instead of rooms, families pleading for attention, overworked nurses, and doctors’ orders ignored.

The 384-page report, published in its entirety Thursday in Asheville Watchdog, provides an almost microscopic analysis of the serious medical, staffing and management issues that local nurses and patients have been decrying ever since HCA, the nation’s largest for-profit hospital chain, took over the Mission Health system in 2019.

Beyond the headlines — four patients dead and dozens of others victimized in 2022 and 2023 by delays in care, neglect, long waits for lab work, unapproved and expired medications, and a litany of other failures by HCA and Mission management — the report by the U.S. Centers for Medicare & Medicaid Services analyzes in detail how the hospital put patients in immediate jeopardy of harm, or even death.

It also outlines HCA-Mission’s plan of correction, a step-by-step process the hospital was required to submit to fix the situations that caused the deficiencies.

According to a CMS letter dated Feb. 15 and obtained by The Watchdogthrough a public records request, CMS has accepted that proposed plan and informed Mission that state inspectors will visit the hospital before Feb. 24 to “to determine if the immediate jeopardy has been removed.”

Investigators reviewed some 100 patient cases, and summarized the records for at least 15.

Here are some of those cases:

Family pleads for help. Provider says, “Not my patient

Patient #28, a 48-year-old man, came to Mission Hospital July 5, 2022, at 9:47 a.m. with potentially life-threatening bacterial meningitis and low blood pressure.

A medication to raise his blood pressure was administered intravenously, but “the patient and IV were not monitored and the bag ran dry,” the report said.

That evening, with alarms going off in the room, a family member sought help from a physician assistant from the trauma team in the hallway.

“The family of the patient was monitoring the BP (blood pressure) and tried to get help from a non-ER provider who was sitting at a computer outside the room and this provider told the family that he could not help them because it was not his patient,” the report stated. “Family is irate about this.”

The director of the trauma team told inspectors that “when a Trauma Team member was in the ED it was to care for a specific consulted trauma patient.” The physician assistant “would not be allowed to touch an IV drip or alarming IV pump of a patient they were not consulted on.”

The physician assistant told inspectors the family asked only for help with an IV alarm. “I told them I can get your nurse, and I did. The family was asking about an IV beeping. If I thought he was coding, I would have made sure he was OK. I did not have that information … Of course, I would respond to help a patient coding. I would not ‘shirk’ a patient needing help.”

A trauma team supervisor told the physician assistant, “We should always respond with compassion to family,” according to the report.

The nurse responsible for Patient #28 was caring for four other patients and had already complained to two supervisors about his workload that day. He was tending to a new trauma patient when the IV ran dry, and Patient #28’s heart stopped beating, known medically as “coding.”

“When I arrived in the room … the code was in progress. I was very upset. I voiced my concerns, I talked to the administration, to the ethics and compliance committee and filed a complaint with HR (human resources). I tried to document this the best I could.”

The IV bag “emptied due to unsafe staffing assignment,” a nurse said in an incident report.

Patient #28 was in the emergency department for nearly 10 hours, during which he went into cardiac arrest twice, according to the report. He died on July 15, 2022, after having been moved to the hospital’s intensive care unit.

Delay in lab tests, patient dies

A 66-year-old patient with chest pain arrived at the emergency department Oct. 17, 2023, and died less than three hours later after suffering a heart attack. A doctor told inspectors, “the expectation for chest pain patients was an EKG within 10 minutes and to be seen by a provider within 10 minutes.”

Instead, the man, identified in the report as Patient #2, waited over an hour  to be “triaged,” or prioritized by severity of the patient’s condition, and an hour and 12 minutes for an EKG.

Paramedics brought the patient to the hospital from his home, where he had experienced chest pain and shortness of breath. “There was potential for things to turn unstable quickly,” a paramedic later told inspectors.

At Mission, the patient was assigned to a room that was already occupied, and waited in the hallway. “Waits had gotten more common recently and it seemed like a staffing issue,” the paramedic told inspectors.

A physician assistant evaluated the patient in the hallway and ordered blood tests. The patient “appeared stable,” and the physician assistant “moved to another patient,” he told inspectors.

“The nurse assigned to Patient #2’s room was busy and not able to triage the patient, so a radio request for help was made,” and another nurse responded, the report said.

Paramedics continued monitoring the patient for more than an hour, unable to leave until he was moved to a room, and they could brief hospital staff on his condition.

Until then, Mission was “counting on EMS to care for (the patients),” the nurse told inspectors.

Medical records showed an EKG and blood work were ordered “STAT,” or immediately, 48 minutes after the patient’s arrival. Another 39 minutes passed before the nurse drew blood.

The lab results had not come back when, a half hour later, the man went into cardiac arrest.

“Called lab to request results of chemistries be available as soon as possible,” an “ER report” stated.

As staff attempted to resuscitate the patient, the lab results began to come back, including one showing a high level of troponin proteins, an indication of a heart attack. The man was pronounced dead 15 minutes before that test result was returned.

The doctor interviewed by inspectors “acknowledged there was a delay for Patient #2,” according to the report, and said “in an ideal situation the patient would have gone straight back to a room and care started.”

“It was an extremely busy day”

The inspectors’ review of the Patient #83, a 74-year-old woman who died Nov. 30, 2023, two days after arriving in the emergency department with dizziness, found physician orders not followed, delays in lab work, and key staff unavailable on a night shift.

Despite urgent orders for blood work, lab results took more than three hours, and the emergency department failed to comply with a doctor’s instructions for continuous heart monitoring and vital signs taken every two hours. A delay of more than nine hours occurred for a lactic acid test that revealed a critically high level, shortly before the patient deteriorated.

A nurse who cared for the patient in a hallway bed told inspectors: “I remember her. It was an extremely busy day… The problem with hallway beds is they have no dedicated monitor. She had a monitor and vital signs ordered. I strongly advocated for her to get moved into a bed with the CNC (clinical nurse coordinator), and it didn’t happen. She didn’t think it was a big deal. We don’t have the capability to link the patient to a monitor in a hallway bed. She wasn’t on a monitor; I spent the afternoon telling the CNC and MD. The doctors don’t have any say, it’s up to the CNC where patients are roomed. I sat behind her all day …I was extremely frustrated.”

“Interview revealed physician orders were not followed for Patient #83,” the report said.

A nursing vice president could not explain the lack of monitoring or vital signs in the emergency department and said the nurse should have alerted a charge nurse. “Interview revealed hospital policy was not followed for Patient #83,” the report said.

Another emergency department nurse told inspectors: “I work on an inpatient unit and was pulled to the ED (emergency department) that day. It’s a revolving door, I don’t recall this patient in particular.” She could not remember why the lactic acid test was not done.

“Interview revealed physician orders for Patient #83 were not followed,” the report said.

A night shift nurse on the floor where the patient was transferred told inspectors: “I did not receive a report on this patient from the ED (emergency department). You have to look up the medical record number and sometimes the charge nurse gets an alert that the patient is coming and will print the face sheet. I had to piece it together and go through the orders.”

The nurse said reaching a phlebotomist — a medical technician who collects blood — had been an ongoing problem on the night shift. “That morning they were not logged into to their i-mobile device [hospital staff’s electronic communication system]. I called the general lab number, and no one answered. I then contacted my house supervisor, and he told me ‘we don’t have another option right now.’”

A laboratory phlebotomist supervisor told inspectors that blood should be collected within 15 minutes on rush orders and the results returned within an hour. “Lab collection for STAT and NOW orders for Patient #83 did not follow hospital policy for lab turnaround times,” the report said.

An incident report completed by a nurse described the problem with Patient #83 as a “delay in care” and the issue as a “lack of timely response to order.” The solution to prevent similar problems, the report said: “Promptly follow orders.”

Patient was in waiting room for 9 hours

Patient #43 came into the emergency department at 4:03 p.m. Aug. 14, 2023, complaining of “chest pain, nausea, clammy, lightheaded, right-side tingling for several weeks,” the report states. He was accompanied by his mother.

The 39-year-old reportedly drank “12 beers a day,” according to the report, and a physician ordered numerous medications soon after he arrived and then again later in the evening. “These orders were not implemented,” the report states repeatedly.

The patient waited nine hours and 56 minutes for alcohol withdrawal medication, which the doctor ordered soon after he arrived. At 1:07 a.m. the next day, he had a seizure.

“I became involved in the patient’s care after he apparently left the waiting room where he was awaiting admission and then had a seizure and struck his head on the sidewalk outside of the ER (emergency room) entrance,” a doctor noted in a medical record. “He has been in the emergency department waiting room for 9 hours…I suspect that he seized due to alcohol withdrawal..”

In an interview with inspectors, the doctor reported, “With the current process it’s still difficult to treat patients in the ED waiting room. The goal was for delays in care to not happen, but especially at night it occurs. I have concerns with delays in patient care. The patient was better off in a more clinical area where they can be monitored.”

An internal report by the hospital said, “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.”

A hospital investigator said, “We continue to work through ways to provide care to patients in the waiting room during peak times of surge and limited staffing.”

The incident report concluded, “Primary Action to Prevent Recurrence: ‘Increase in Staffing/Decrease in Workload.’”

“[M]onitoring of patients in hallway beds (is) a concern.”

Patient #29, a 78-year-old woman, came to the emergency department April 5, 2022, at 2:51 p.m. with an abnormal heart rhythm. Earlier that day, she fell in a bathroom and fractured her leg.

“[S]he does have significant bleeding from her right lower leg… bleeding is controlled… the leg is splinted…” an EMS narrative stated.

Her blood oxygen level as measured by pulse oximetry was at 94 percent — 95 to 100 percent is normal — before she arrived at Mission. At 4:30 p.m., it had dropped to 90 percent — considered to be critically low — “with no evidence of oxygen administration at hospital,” the report states.

The patient’s family, according to an emergency department manager, called a nurse over because “she didn’t look good.”

A nurse gave her Dilaudid, a narcotic, for pain the patient rated as 9 on a 10-point scale. She was then moved out of a room and into a hallway.

A doctor was called  at 7 p.m. after a nurse found Patient #29 unresponsive. She was pronounced dead  at 7:09 p.m.

The patient had one set of vital signs completed in more than four hours. “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 states.

A nurse described the death as unexpected in a “patient event record” that also said “there was no witness to event.” The patient’s daughter was at her bedside when she died, records state.

“[M]onitoring of patients in hallway beds (is) a concern,” a doctor interviewed in the report said.

Patient gets expired cancer drug

A cancer patient received an expired dose of an intravenous chemotherapy drug on March 4, 2023, an oncologist told inspectors.

The unnamed oncologist said Mission’s “oncology unit lost valuable nurses which led to the hiring of new/inexperienced staff, and increased use of travel staff. The changes in staff led to an increase in errors.”

The oncologist also said that Mission no longer admitted cancer patients directly to the oncology unit, requiring them instead to go through the emergency department, which put “patients at an increased risk for infection. Additionally, the unit no longer admitted complex cases of oncology patients because those cases were referred to other hospitals.”

The oncology unit manager told inspectors that in April 2023 the oncology unit adopted a more detailed treatment administration checklist to assist the oncology nurses and the pharmacy department.

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 [email protected]. Sally Kestin is a Pulitzer Prize-winning investigative reporter. Email [email protected]. The Watchdog’s reporting is made possible by donations from the community. To show your support for this vital public service go to