By Ted Clifford
Mission Hospital has hired an outside consultant following its most recent Immediate Jeopardy sanction and committed to federal regulators that it will make sweeping changes, including reevaluating “the capacity and competency” of its leadership and staff, according to its enhanced plan of correction obtained by Asheville Watchdog.
Mission leadership promised a number of steps and improvements in the plan required by the U.S. Centers for Medicare & Medicaid Services following its third Immediate Jeopardy in less than two years. These include commissioning an analysis on the root causes of its deficiencies in care, “resetting” the hospital’s relationship with CMS, and changing its blood transfusion policies.
“Mission understands the responsibility we have for the health and safety of our community and the need for our patients to have confidence in their Hospital,” administrators wrote in the plan, which was approved by CMS. “Our patients deserve a safe hospital, one that consistently delivers high-quality healthcare.”
Administrators described six “recurring themes” at the heart of the hospital’s challenges: leadership oversight and governance; staffing and staffing assignments; compliance with policies, protocols and procedures; emergency department safety and quality; quality outlier performance; and patient and staff communication.
“Mission has already undertaken much of the work needed to address the deficiencies,” administrators wrote.
In addition to its pledge to “reevaluate the capacity and competency of our leaders and staff,” Mission also promised to “commit the financial or other resources necessary” to ensure their “capacity and competency.”
However, the plan made no specific reference to short staffing, which employees and advocates have repeatedly emphasized is the most significant underlying problem at Mission.
Enhanced Plan Of Correction 1.30.2026Download
The Watchdog requested comment from Nancy Lindell, spokesperson for HCA’s North Carolina division, for this story but did not hear back before publication.
While the most recent Immediate Jeopardy, which was imposed in late January, was officially lifted February 9, Mission is still out of compliance with some federal standards of care. The hospital has until July 29 to address those or it will again risk being denied reimbursement from Medicaid and Medicare.
To help address these issues, administrators said they had hired Bryant Healthcare Consultants to develop and ensure compliance with improved processes. The consultants would help Mission prepare a report on its progress that would be submitted to CMS on the 5th of every month.
A root cause analysis was set to be completed March 2, according to the report. That analysis will then be used to help develop what Mission has described as a “comprehensive action plan” to address the hospital’s issues.
The report also described in general terms intended changes to the hospital’s grievance process in order to limit the number of complaints being made to outside authorities.
“We will create and complete a comprehensive communication campaign to strengthen patient and staff understanding of the grievance process and to encourage them to bring grievances directly to Mission,” administrators wrote.
Measles, influenza and blood transfusions addressed in plan
Mission’s plan of correction specifically addressed several incidents revealed by the most recent Immediate Jeopardy. These were the death of an 88-year-old orthopedic patient who died after going 13 hours without a needed blood transfusion, a measles exposure in Mission’s emergency department waiting room and an incident in which a patient with influenza was brought to the wrong unit.
In their plan, Mission administrators pledged to improve notification given by the hospital labs to staff about critically low values in a patient’s tests and to shift the hospital’s policy on when a blood transfusion must be given to be more in line with national standards. The plan also states that staff will be retrained on how often vital signs need to be taken for orthopedic patients.
Many of the corrections that administrators outlined were to be accomplished through educating providers through newsletters, training and “huddles” – brief meetings held during a shift.
In one example, staff would also receive additional training on “the importance of adding bed attribute details” and “transport process and expectations” in order to address issues leading to a patient being taken to the wrong room.
The failure to control a measles exposure in Mission’s emergency department would be addressed in part by new patient screening procedures that included a “masking prompt” for patients arriving with respiratory symptoms, administrators wrote.
Additionally, administrators said they were improving signage by using brighter colors and adding more “respiratory etiquette information stands” at the main entrances of the hospital.
There was no mention in the report of how Mission would address the underlying problems that led to short-staffed night nurses falsely documenting giving a teenage patient psychiatric medication or a patient nearly choking another nurse into unconsciousness.
The plan also did not address issues in a case where staff didn’t respond to an urgent request for heart monitoring before a patient’s heart stopped. The unidentified patient suffered brain damage and later died in hospice.
Typically a plan of correction accompanies CMS’s report on the causes of the Immediate Jeopardy. However, in a letter from CMS dated Jan. 26, federal regulators rejected Mission’s initial draft for its plan of correction, and its detailed report on the hospital’s deficiencies in care did not include Mission’s proposed remedies.
Due to the “serious findings” from their most recent survey of the hospital, Mission would need to revise the enhanced plan of correction, regulators wrote.
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Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Ted Clifford is The Watchdog’s investigative reporter focusing on healthcare. He can be reached via email at tclifford@avlwatchdog.org. The Watchdog’s local 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/.
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