NC Hospital Placed in ‘Immediate Jeopardy’ by Feds for 3rd Time Over Patient Safety

Mission Hospital in Asheville, North Carolina, has once again been placed under Immediate Jeopardy review, one of the most serious enforcement actions considered by federal regulators. The recommendation followed a state inspection that identified multiple patient safety deficiencies between July and September 2025, as outlined by the North Carolina Department of Health and Human Services (NCDHHS). NCDHHS submitted those findings to the Centers for Medicare & Medicaid Services (CMS) on October 10, 2025, recommending that the federal agency classify the hospital as being in Immediate Jeopardy.

CMS has accepted the state’s recommendation and provisionally recognized the Immediate Jeopardy status, but has not yet assigned formal deficiency tags. Those tag designations, known as Condition-level citations, will be issued following a federal validation survey later this month to determine whether Mission’s corrective action plan satisfies regulatory standards. As of October 22, CMS officials confirm the hospital remains under Immediate Jeopardy review pending verification of compliance.

NCDHHS surveyors reported several safety lapses at Mission Hospital, including,

• Patient misidentification
• Telemetry monitoring failures
• Infection control breaches.
• Specific incidents cited include breaches of protocol during cardiac monitoring and incomplete communication during patient transport.
• These findings led regulators to determine that patient conditions had been placed at risk of serious harm or death, a level that meets CMS’s Immediate Jeopardy threshold, and this is not the first time they’ve received this violation.

This marks the third time Mission Hospital has undergone an Immediate Jeopardy investigation since its 2019 acquisition by HCA Healthcare. Each prior designation—most recently lifted in June 2024—was temporary and resolved after CMS verified compliance.

According to documentation from NCDHHS and statements provided to Becker’s Hospital Review and Blue Ridge Public Radio, CMS lifted the most recent Immediate Jeopardy designation in June 2024 after a successful state re-inspection.

The recurrence of safety concerns in 2025—again involving patient identification, telemetry monitoring, and infection control—has renewed questions about the hospital’s systems for sustained quality improvement. Regulators and patient safety advocates have pointed to potential systemic factors, such as staffing, communication, and process oversight, as areas that may warrant closer review. 

As scrutiny intensifies, Mission Hospital leadership has responded publicly, outlining corrective actions already in place and disputing portions of the state’s findings.

Mission Hospital, part of the HCA Healthcare network, has publicly addressed the Immediate Jeopardy designation and pushed back on some of the state’s claims. CEO Greg Lowe said that the hospital “implemented extensive corrective action plans before the inspection” and stated that “many findings were inaccurately represented.”

In an internal message to staff, Lowe described portions of the inspection as “unusual” and indicated that there may have been external pressure on state surveyors to find deficiencies. He emphasized that Mission has already submitted its corrective plan to CMS and “welcomes a follow-up survey,” expressing confidence in the hospital’s ability to maintain high standards of care.​

A broader public statement released on October 21, 2025, reiterated the same message:

The Immediate Jeopardy ruling highlights the importance of maintaining consistent safety practices at every level of care, particularly for nursing professionals who play a central role in patient protection. The Joint Commission identifies patient misidentification as a top safety risk, and simple verification practices such as confirming two identifiers and scanning barcodes remain among the most effective safeguards. 

Lapses in telemetry monitoring were also central to the state’s findings, with a 2023 Journal of Patient Safety study estimating that 7% of serious hospital events are linked to interruptions in monitoring or delayed alarm responses, especially during patient transport.

Effective communication across handoffs helps prevent avoidable cardiac incidents, while adherence to infection prevention standards such as thorough hand hygiene, appropriate use of personal protective equipment (PPE), and consistent cleaning practices continues to be a cornerstone of hospital safety programs, as recommended by the CDC and WHO. 

Commitment to Compliance and Patient Safety

This marks the third Immediate Jeopardy investigation for Mission Hospital since its 2019 acquisition by HCA Healthcare. Federal regulators will revisit the facility in late October to determine whether the implemented corrective actions meet compliance standards.​

Until then, the case stands as a timely reminder for nurses nationwide: vigilance, accountability, and adherence to core safety protocols are not optional. They remain essential pillars of safe, high-quality patient care. 

🤔 Nurses, share your thoughts in the discussion forum below.