Mission Hospital’s violation of the Emergency Medical Treatment & Labor Act (EMTALA) involved a 66-year-old patient’s fatal heart attack following delays in triage and medical screening in its emergency department, according to a U.S. Centers for Medicare & Medicaid Services report obtained by Asheville Watchdog.
His death is one of four at HCA Healthcare-owned Mission between early 2022 and late 2023 cited by federal investigators in findings that have threatened the hospital’s Medicare and Medicaid funding.
The CMS report, obtained Friday, details Mission’s violation of the Emergency Medical Treatment & Labor Act (EMTALA), which The Watchdog was first to report earlier this month. The report also includes the hospital’s plan to fix the issues that contributed to the violation.
CMS has approved that plan, according to a March 26 letter from CMS to the hospital’s CEO obtained by The Watchdog, which has reached out to an HCA and Mission spokesperson for comment.
The patient, identified by CMS as Patient No. 2, came to the hospital with chest pain after he fainted at home. He experienced several delays in care, which ultimately contributed to his death, according to the report.
The CMS report details the timeline for care:
- Patient 2 came into the emergency department at 5:53 p.m., complaining of chest pain. He had described to EMS staff that his pain was 6 on an scale of 1 to 10, with 10 being the most acute. There was no bed available when he arrived, according to a nurse interviewed by federal investigators.
- His labs were ordered at 6:41 pm., nearly an hour after his arrival.
- He was triaged at 7 p.m. and an EKG was completed five minutes later. At that point, his pain was 7 on a scale of 1 to 10.
- He was transferred from EMS to hospital staff care at 7:07 p.m., nearly an hour and 20 minutes after he arrived.
- Nurses collected labs at 7:20 p.m.
- He went into cardiac arrest at 7:53 p.m. and died soon afterward while staff tried to resuscitate him.
The hospital had a protocol for patients with chest pain, “but the protocol had to be activated by a provider,” leading to a delay in care, according to one nurse interviewed by federal investigators.
Another nurse told investigators that Patient 2’s labs were not drawn until after he was placed in a room.
“Until patients were in a room and care handed-off from EMS, interview revealed, they were ‘counting on EMS to care for (the patients),’” the nurse told investigators.
EMTALA ensures public access to emergency services regardless of ability to pay. It requires Medicare-participating hospitals to provide a medical screening when a request is made for examination or treatment for an emergency condition, according to CMS.
In a March 26 letter to CMS in response to the findings, Mission Hospital CEO Chad Patrick said, “The concerns of CMS have been taken very seriously by the hospital Administration, the Medical Executive Committee of the Medical Staff, and the Board of Trustees.”
“You can be assured that the highest priority has been assigned to correcting the deficiencies identified at Mission Hospital.”
Mission’s plan of correction includes audits of the hospital’s triage system, education for nursing staff, and increased patient tracking measures, among other fixes. It does not mention hiring of more staff or retaining current staff, which Mission nurses and local advocates continue to urge as measures HCA must take to stave off chronic understaffing issues. CMS will monitor Mission’s compliance with the plan for the next two months.
CMS has given Mission until June 5 to correct the issues that led to the EMTALA violation or face the loss of Medicare and Medicaid funding.
“When the North Carolina State Survey Agency has determined that the noncompliance with EMTALA requirements has been corrected, CMS will withdraw its current termination action,” CMS said in its March 26 letter to Patrick. “Failure to correct the deficient practice by June 5, 2024, will result in the termination of your Medicare provider agreement.”
The EMTALA violation is the second federal citation that threatens Mission’s Medicare and Medicaid funding. In December, CMS placed Mission in immediate jeopardy, determining that conditions in a number of areas in the hospital endangered patients. A CMS report on the finding of immediate jeopardy detailed the deaths of four patients, including Patient No. 2, as well as deficiencies in care for several others.
The hospital recently corrected issues that led to the immediate jeopardy finding, according to CMS.
Mission’s deficiencies in care and its violation of EMTALA and the five patients deaths were revealed during a North Carolina Department of Health and Human Services and CMS investigation conducted in November, according to several CMS letters obtained by The Watchdog.
The Watchdog had reported in August 2023 on nurses’ concerns that the hospital’s lax emergency department transfer procedures were endangering patients. For two years, the nurses had sent formal complaints to NCDHHS, but as The Watchdog reported, the agency had not sent investigators to the hospital, citing staff shortages.
Details of the NCDHHS investigation were outlined in a 384-page report CMS made public in February and which detailed numerous occurrences of patient safety and practice errors.
[Correction: An earlier version of this story incorrectly described the death of the 66-year-old patient as the fifth at Mission Hospital chronicled by federal investigators. His death was previously reported by investigators.]
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. 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/donate.
I have been following your articles about Mission Hospital. THANK YOU for sharing your findings with the public. Thankfully it has not been my personal experience. My last encounter with the ER was Dec 2022 when my daughter was brought in. She went to urgent care the night before & when I called 911 the next morning, Leicester EMS came & said since she had been seen the night before, they could take her in, but she would likely sit all day in the waiting room. I then took her back to urgent care & insisted they call for an ambulance. She was taken to an ER room immediately & spent 8+ hours there. We were fortunate that her nurse knew the dire circumstances my daughter was in & she rarely left her side. By late night, my daughter was moved to ICU, where she died 8 days later.
I did notice that the ER waiting room was full when I arrived early afternoon & when I left the hospital after 1 AM, I saw many of the same people still waiting to be seen.
Earlier in 2022, my daughter took me to the ER. I was later told that it was COPD exasperation, but when we arrived, I was immediately taken back for an EKG. I guess we were lucky.
When the new Advent Hospital is built in Weaverville, I will use their services for emergency visits. Mission Hospital should have never been sold to HCA. It was the worst decision ever made for our community. I know AVL Watchdog will continue to follow this. Thank you!
The problem I see with these regulatory agencies is that they cite the hospital and give them a relatively short timeframe to correct major deficiencies where the root cause is short staffing; however, fixing a short staffing issue is generally not a short-term (90-day) fix to implement unless you can do it with contract labor and I would imagine that is difficult to do with doctors. So even if HCA were willing to address the short staffing issue (which we know they are not), that is not a solution they can propose and implement in the timeframe specified. So therefore they are putting other bandaids in place and the regulators are accepting those bandaids.
Until the regulators start asking for longer term plans and start specifying that staffing issues are part of the underlying issues they are seeing and that those issue be addressed, I don’t see that they will be part of the solution to our issue with Mission/HCA.
Just how long are the authorities going to let this continue, giving extension after extension, while patients remain in jeopardy?
I would love to see Asheville Watchdog do a comparison study/article on our three local hospitals – Advent, Pardee & Mission – with an eye to determining if all three hospitals are experiencing similar difficulties. I’ve not heard of Advent or Pardee having these issues, but is that because they are not or because we’ve just not heard about it?
The CMS oversight of HCA Mission is a complete farce. HCA runs the show here and elsewhere because they’re a many time over billion dollar business …and that’s all they are. The “healthcare” they provide is a guise at best.
I’m surprised that HCA isn’t facing several malpractice lawsuits.
I’ve been told the tort reform law regarding malpractice that the General Assembly passed in 2011 has made it really difficult to win a malpractice suit in NC. There are a number of people who have what one would think are obvious malpractice cases against HCA’s version of Mission Health, but they can’t find lawyers who will take on the case.
True. When my husband admitted and given a morphine shot for pain I saw that it immediately caused a red line going towards his heart and called for the nurse who immediately said he is allergic to it and took measures to correct it. Two days later
after he was admitted I came back to see him and he was in much worse condition and on a morphine drip! I went immediately to the nurses station and told them to check the records and they said, “Oh my God you are right!” and they then stopped the drip.
Five days later on Christmas Day he actually stopped breathing but was revived and was admitted to ICU and given a 2 % chance of surviving. He was again given a morphine drip! I kept complaining and was told that I would not be permitted to see him if I didn’t stop complaining about the morphine and that he needed it. 37 days later when he had come round a bit the nurse asked him if he was allergic to morphine and he nodded his head. They took him off of it and he was transferred out of ICU into a regular room about 3 days later and then to Care Partners for 3 months of rehab. He was finally diagnosed with Gillian Barre Syndrome but in his case he was fully paralyzed he could not even open his eyes. He has partially recovered but has no feeling from the knee down and from the elbow down.
Sounds all too familiar, unfortunately. When I finally received my husband’s medical records (redacted after being sent to Risk Management) after his death at HCA I found a provider actually dictated into his medical record “Spouse asks too many questions”. I vomited when I read that… shut the 30 pound box and haven’t opened it again.
HCA is facing serval malpractice lawsuits, one from the city of Ashville, 1 from Brevard, County of Buncombe and Madison County. Also being sued by the Mayor of Canton Zeb Smathers.
It’s chilling to think that what happened to this patient occured at pretty much exactly the same time (evening of Oct. 17) that the Independent Monitor was holding a public meeting explaining that he had no authority to review quality-of-care issues.
Gosh, everyone says that Mission is STILL the best hospital to go if you are having a heart attack. Come on upper admin staff, please clean up the ER. We know there are great people who work in the Heart Tower, if only the patients live to get there.
You sure? Cause I ain’t seen no good ones in 4yrs.
In June of 2023, I walked into Mission Hospital complaining of chest pain. Despite a large number of people in the waiting room, I was immediately taken to triage and my blood was drawn. I would say this happened within about 10 or 15 minutes. My troponin level was high meaning I either had significant angina or a heart attack. The test result was returned as well in a very short period of time. I was taken to a room, where I was given an IV and placed on machines to monitor my vitals and a continuous EKG. This all happened in less than an hour. I then saw the doctor on call and he said my condition was stable and that I would likely need a stent. All this occurred on a Sunday. I received the stent the next and was released the following day. I have nothing but praise for the staff of Mission Hospital.
How long have you been working at Mission? Maybe it’s the insurance. For it to take an hour to hand off a patient to get transferred from EMS to the ER is disgusting.
Idiots!!!! I will never go back there again!
This is terribly sad, and his death might had been avoided with proper care. He was taken there because of Mission’s heart services, but no matter what services are listed as available on paper, if you cannot access them in a timely manner, you might as well not go. If he has been taken to Advent or UNC, they may have been able to stabilize before transferring him up to heart tower. However, there is ANOTHER problem, that all admits and transfers are processed through the ER, which is more risk for lack of care, waiting for tests to be repeated, providers to place orders and then waiting for a bed. Let’s say she made it through all of that, what is the patient to nurse ratio right now in CICU? I don’t know right now, but we know these ratios have been unsafe in many areas of the hospital and their other medical centers.
Seems the corrective measures that are purportedly in place are not tangibly beneficial to the patients. Having been there twice in the past week or so with patients. Both waited ridiculously long times, both were heart related, both were discharged without proper care. A week apart, on weekdays, one early morning and the other midday. There are not enough staff period. They don’t have folks to transport, clean rooms, operate imaging at capacity, process labs, IV/Port Access team, maintenance, technicians, etc. There aren’t enough supplies still, so staff are spending time hunting for things rather than having fully stocked supply areas. I’m now concerned, and nearly convinced, these corrective measures are all just posturing. I believe the community and staff have to vigorously continue to file formal complaints, as it really is the only proper recourse we have.
In April 2023 I took a family member to Mission’s ER with symptoms that we were concerned might suggest a heart problem. In the long and very slow-moving line inside the front door, we found ourselves behind a middle-aged man who was clearly in distress. He told us that after several previous heart attacks, he knew he was having another one. He was experiencing swelling, discomfort, and labored breathing. The other people waiting in line, finally flagged down a volunteer and requested that he at least be provided a seat. She disappeared, and, after sometime, was able to locate a wheelchair from another floor. At no point was he moved to the front of the line or approached by any of the medical personnel, though the volunteer assured us she had made them aware of his situation. After observing this neglect for far too long, I determined it was better to take my relative to.Advent. There, almost the first question heard in the emergency room was, “Is anyone experiencing chest pain?” We found the care at Advent to be prompt, caring, and excellent.